Common use of Acceptance of Group Agreement Clause in Contracts

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Evidence of Coverage CA-2562a21, Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 888-901-4636. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 2022 Evidence of Coverage CA-2562a21CA-2562a22, Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Evidence of Coverage CA-2562a21, Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Kaiser Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Kaiser Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 2024 Evidence of Coverage CA-2562a21, CA-2562a24 Important Notice Under Federal Health Care Reform Xxxxxx Kaiser Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Evidence of Coverage CA-2562a21, Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 888-901-4636. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 2024 Evidence of Coverage CA-2562a21, CA-1888a24 Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Kaiser Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Kaiser Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 2024 Evidence of Coverage CA-2562a21, C0F2801466000 Important Notice Under Federal Health Care Reform Xxxxxx Kaiser Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 2023 Evidence of Coverage CA-2562a21, CA-2562a23 Important Notice Under Federal Health Care Reform Xxxxxx Kaiser Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Options, Inc. Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization Options, Inc. 2021 Access PPO Evidence of Coverage CA-2562a21, C496206498700 Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington Options, Inc. (“KFHPWAKFHPWAO”) recommends each Member choose a Network Personal Physicianpersonal physician. This decision is important since the designated Network Personal Physician personal physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician personal physician who participates in one of the KFHPWA KFHPWAO networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physicianpersonal physician, and for a list of the participating Network Personal Physicianspersonal physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-901- 4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA KFHPWAO or from any other person (including a Network Personal Physicianpersonal physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA KFHPWAO network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-000- 0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA KFHPWAO will provide the information regarding the types of plans offered by KFHPWA KFHPWAO to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 1-888-901-4636. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Kaiser Foundation Health Plan of Washington Options, Inc. Evidence of Coverage Xxxxxx Kaiser Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Options, Inc. 2023 Access PPO Evidence of Coverage CA-2562a21736EID2023C, Important Notice Under Federal Health Care Reform Xxxxxx Kaiser Foundation Health Plan of Washington Options, Inc. (“KFHPWAKFHPWAO”) recommends each Member choose a Network Personal Physicianpersonal physician. This decision is important since the designated Network Personal Physician personal physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician personal physician who participates in one of the KFHPWA KFHPWAO networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physicianpersonal physician, and for a list of the participating Network Personal Physicianspersonal physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-901- 4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA KFHPWAO or from any other person (including a Network Personal Physicianpersonal physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA KFHPWAO network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-000- 0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA KFHPWAO will provide the information regarding the types of plans offered by KFHPWA KFHPWAO to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880-901000-4636000-0000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 2020 Evidence of Coverage CA-2562a21, 801EID062020-2 Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 888-901-4636. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Evidence of Coverage CA-2562a21, Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Options, Inc. Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Options, Inc. 2022 Access PPO Evidence of Coverage CA-2562a21C0B2626498800, Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington Options, Inc. (“KFHPWAKFHPWAO”) recommends each Member choose a Network Personal Physicianpersonal physician. This decision is important since the designated Network Personal Physician personal physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician personal physician who participates in one of the KFHPWA KFHPWAO networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physicianpersonal physician, and for a list of the participating Network Personal Physicianspersonal physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-901- 4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA KFHPWAO or from any other person (including a Network Personal Physicianpersonal physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA KFHPWAO network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-000- 0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA KFHPWAO will provide the information regarding the types of plans offered by KFHPWA KFHPWAO to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880-901000-4636000-0000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization 2021 Evidence of Coverage CA-2562a21, Important Notice Under Federal Health Care Reform Xxxxxx Kaiser Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-888000-901000-46360000. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 10-000-000-0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 8880- 000-901000-46360000. Table of Contents

Acceptance of Group Agreement. The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments issued during the term of this Group Agreement, upon receipt by KFHPWA KFHPWAO of any amount of premium payment. Your Xxxxxx Foundation Health Plan of Washington Options, Inc. Evidence of Coverage Xxxxxx Foundation Health Plan of Washington A nonprofit health maintenance organization Options, Inc. 2021 Access PPO Evidence of Coverage CA-2562a21, C496206498800 Important Notice Under Federal Health Care Reform Xxxxxx Foundation Health Plan of Washington Options, Inc. (“KFHPWAKFHPWAO”) recommends each Member choose a Network Personal Physicianpersonal physician. This decision is important since the designated Network Personal Physician personal physician provides or arranges for most of the Member’s health care. The Member has the right to designate any Network Personal Physician personal physician who participates in one of the KFHPWA KFHPWAO networks and who is available to accept the Member or the Member’s family members. For information on how to select a Network Personal Physicianpersonal physician, and for a list of the participating Network Personal Physicianspersonal physicians, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-888-901-901- 4636. For children, the Member may designate a pediatrician as the primary care provider. The Member does not need Preauthorization from KFHPWA KFHPWAO or from any other person (including a Network Personal Physicianpersonal physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA KFHPWAO network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1-000-000-000- 0000. Women’s health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Member and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA KFHPWAO will provide the information regarding the types of plans offered by KFHPWA KFHPWAO to Members on request. Please call Xxxxxx Permanente Member Services at (000) 000-0000 in the Seattle area, or toll-free in Washington, 1- 1-888-901-4636. Table of Contents