WIXLIB

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesCoverage Period: Beginning on or after 01/01/2021: Core VisitsPlus Gold LXAll plans offered and underwritten by Kaiser Foundation Health Plan of WashingtonCoverage for: Individual / Family Plan Type: HMOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare 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 www.kp.org/plandocumentsor call 1-888-901-4636 (TTY: 711). 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 www.healthcare.gov/sbc-glossary or call 1-888-901-4636 (TTY: 711) to request a copy.Important QuestionsAnswersWhat is the overalldeductible? 600 Individual / 1,200 FamilyAre there servicescovered before you meetyour deductible?Yes. Preventive care and services indicated inchart starting on page 2.Why This Matters:Generally, you must pay all of the costs from providers up to the deductibleamount before this plan begins to pay. If you have other family members on theplan, each family member must meet their own individual deductible until thetotal amount of deductible expenses paid by all family members meets theoverall family deductible.This plan covers some items and services even if you haven’t yet met thedeductible amount. But a copayment or coinsurance may apply. For example,this plan covers certain preventive services without cost-sharing and before youmeet your deductible. See a list of covered preventive services are-benefits/.Are there other deductiblesNo.for specific services?You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan?The out-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in this plan, they have to meet their own out-ofpocket limits until the overall family out-of-pocket limit has been met. 7,900 Individual / 15,800 FamilyPremiums, balance-billing charges, health careWhat is not included in thethis plan doesn’t cover, and services indicated inout-of-pocket limit?chart starting on page 2.Will you pay less if youuse a network provider?Yes. See www.kp.org/wa or call 1-888-901-4636(TTY: 711) for a list of network providers.Do you need a referral tosee a specialist?Yes, but you may self-refer to certain specialists.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.This plan uses a provider network. You will pay less if you use a provider in theplan’s network. You will pay the most if you use an out-of-network provider, andyou might receive a bill from a provider for the difference between the provider’scharge and what your plan pays (balance billing). Be aware your networkprovider might use an out-of-network provider for some services (such as labwork). Check with your provider before you get services.This plan will pay some or all of the costs to see a specialist for covered servicesbut only if you have a referral before you see the specialist.Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices You May NeedPrimary care visit to treatan injury or illnessIf you visit a healthcare provider’soffice or clinicIf you have a testSpecialist visitWhat You Will PayNetwork ProviderNon-Network Provider(You will pay the least)(You will pay the most) 15 / visit, deductible does notNot coveredapply 35 / visit, deductible does notNot coveredapplyPreventive care/screening/ No charge, deductible doesnot apply.immunizationNoneNot coveredNoneX-ray services: 20 / visit,deductible does not applyOther lab services: 20 / visit,deductible does not applyNot coveredImaging (CT/PET scans,MRIs)25% coinsuranceNot coveredPreferred generic drugs 15 (retail); 10 (mail order) / prescription,deductible does not apply.Not covered 45 (retail); 40 (mail order) / prescription,deductible does not apply.Not coveredNon-preferred drugsNoneYou may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.Diagnostic test (x-ray,blood work)If you need drugs totreat your illness orconditionMore informationPreferred brand drugsabout prescriptiondrug coverage isavailable atwww.kp.org/waLimitations, Exceptions, & Other ImportantInformation40% coinsurance (retail);35% coinsurance (mail order) / Not coveredprescriptionPreauthorization required or will not becovered.Up to a 30-day supply (retail); up to a 90-daysupply (mail order). Subject to formularyguidelines. After the first fill, maintenance drugsare required to be filled at a KFHPWA Clinic orthrough KFHPWA mail order.Up to a 30-day supply (retail); up to a 90-daysupply (mail order). Subject to formularyguidelines. After the first fill, maintenance drugsare required to be filled at a KFHPWA Clinic orthrough KFHPWA mail order.Up to a 30-day supply (retail); up to a 90-daysupply (mail order). Subject to formularyguidelines, when approved through theexception process. After the first fill,maintenance drugs are required to be filled at aKFHPWAO Clinic or through KFHPWAO mailPage 2 of 7

Common MedicalEventServices You May NeedSpecialty drugsIf you haveoutpatient surgeryIf you needimmediate medicalattentionIf you have ahospital stayWhat You Will PayNetwork ProviderNon-Network Provider(You will pay the least)(You will pay the most)40% coinsurance (retail)Facility fee (e.g.,25% coinsuranceambulatory surgery center)Physician/surgeon fees25% coinsuranceNot coveredorder.Up to a 30-day supply (retail). Subject toformulary guidelines, when approved throughthe exception process.Not coveredNoneNot coveredNoneYou must notify Kaiser Permanente within 24hours if admitted to a Non-network provider;limited to initial emergency only.Emergency room care25% coinsurance25% coinsuranceEmergency medicaltransportation25% coinsurance25% coinsuranceUrgent care 15 / primary care visit or 35 /specialty visit, deductible does 25% coinsurancenot applyFacility fee (e.g., hospitalroom)25% coinsuranceNot coveredPhysician/surgeon fees25% coinsuranceNot coveredIf you need mental Outpatient serviceshealth, behavioralhealth, or substanceInpatient servicesabuse servicesLimitations, Exceptions, & Other ImportantInformation 15 / visit, deductible does notNot coveredapply25% coinsuranceNot coveredOffice visits25% coinsuranceNot coveredChildbirth/deliveryprofessional services25% coinsuranceNot coveredIf you are pregnantNoneNon-Network providers covered whentemporarily outside the service area.Preauthorization required or will not becovered.Preauthorization required or will not becovered.NonePreauthorization required or will not becovered.Cost sharing does not apply for preventiveservices. Maternity care may include tests andservices described elsewhere in the SBC (i.e.ultrasound.)You must notify Kaiser Permanente within 24hours of admission, or as soon thereafter asmedically possible. Newborn services costshares are separate from that of the mother.Page 3 of 7

Common MedicalEventServices You May NeedChildbirth/delivery facilityservices25% coinsuranceNot coveredHome health care25% coinsuranceNot coveredRehabilitation servicesOutpatient: 35 / visit,deductible does not applyInpatient: 25% coinsuranceNot coveredOutpatient: 35 / visit,deductible does not applyInpatient: 25% coinsuranceNot covered25% coinsuranceNot coveredDurable medical equipment 25% coinsuranceNot coveredIf you need helprecovering or haveother special health Habilitation servicesneedsSkilled nursing careNo charge, deductible doesnot applyNo charge for refractive exam,Children’s eye examdeductible does not apply.No charge, deductible doesChildren’s glassesnot apply.Children’s dental check-up Not coveredHospice servicesIf your child needsdental or eye careWhat You Will PayNetwork ProviderNon-Network Provider(You will pay the least)(You will pay the most)Not coveredNot coveredNot coveredNot coveredLimitations, Exceptions, & Other ImportantInformationYou must notify Kaiser Permanente within 24hours of admission, or as soon thereafter asmedically possible. Newborn services costshares are separate from that of the mother.130 visit limit / year. Preauthorization requiredor will not be covered.Outpatient: 25 visit limit / year. Inpatient: 30day limit / year. Services with mental healthdiagnoses are covered with no limit.Inpatient: Preauthorization required or will notbe covered.Outpatient:25 visit limit / year. Inpatient: 30day limit / year. Services with mental healthdiagnoses are covered with no limit.Inpatient: Preauthorization required or will notbe covered.60-day limit / year. Preauthorization requiredor will not be covered.Subject to formulary guidelines. Preauthorizationrequired or will not be covered.Preauthorization required or will not becovered.Limited to 1 exam / 12 months.Limited to one pair of frames and lenses orcontact lenses / year.NonePage 4 of 7