Common use of Benefits Details Clause in Contracts

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber pays $1,500 per calendar year for Subscriber only coverage Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 per calendar year for Subscriber only coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. After Deductible, Member pays 20% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber Member pays $1,500 3,000 per Family Unit per calendar year for Subscriber only family coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 7,000 per calendar year for Subscriber only family coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. After Deductible, Member pays 20% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber Member pays $1,500 1,000 per Member per calendar year for Subscriber only coverage or $2,000 per Family Unit per calendar year Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 3,000 per Member or $6,000 per Family Unit per calendar year for Subscriber only coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays $30 Copayment and 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays $30 Copayment and 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays $30 Copayment and 20% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. After Deductible, Member pays 20% Plan Coinsurance ambulance coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance ambulance coinsurance Hospital-to-hospital ground transfers: After Deductible, No charge; Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays $30 Copayment and 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays $30 Copayment and 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWAKFHPWAO’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Under the Out-of-Network option, Members shall be required to pay any difference between the Out-of-Network Provider’s charge for services and the Allowed Amount, except for Emergency services or services provided by a non-Network provider at a Network Facility. Preferred Provider Network Out-of-Network Annual Deductible Subscriber Member pays $750 per Member per calendar year or $1,500 per Family Unit per calendar year for Subscriber only coverage Shared with the Preferred Provider Network Coinsurance Plan Coinsurance: Member pays 2010% of the Allowed Amount Plan Coinsurance: Member pays 30% of the Allowed Amount Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 3,000 per Member or $6,000 per Family Unit per calendar year for Subscriber only coverage Shared with the Preferred Provider Network The following Out-of-pocket Pocket Expenses apply to the Out-of-pocket Pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-Covered Services The following Out-of-Pocket Expenses apply to the Out-of-Pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-Pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Preferred Provider Network Out-of-Network Acupuncture needle treatment, limited to a combined total of 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Exclusions: Herbal supplements; reflexology; any services not within the scope of the practitioner’s licensure Allergy Services Preferred Provider Network Out-of-Network Allergy testing. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Ambulance Preferred Provider Network Out-of-Network Emergency ground or air transport to any facility. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 10% Plan Coinsurance Non-Emergency ground or air interfacility transfer. Under the Preferred Provider Network option, non- Emergency ground or air interfacility transfer to or from a Preferred Provider Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for PreauthorizationKFHPWAO. After Deductible, Member pays 2010% Plan Coinsurance Hospital-to-hospital ground transfers: No After Deductible, Member pays 10% Plan Coinsurance Under the Preferred Provider Network option, hospital-to- hospital ground transfers when Preauthorized by KFHPWAO. Non-emergent air transportation requires Preauthorization. charge, Member pays nothing Cancer Screening and Diagnostic Services Preferred Provider Network Out-of-Network Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA KFHPWAO and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing After Deductible, Member pays 30% Plan Coinsurance Routine Mammography: After Deductible, Member pays 30% Plan Coinsurance Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Circumcision Preferred Provider Network Out-of-Network Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 2010% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 2010% Plan Coinsurance Outpatient Services: After Deductible, Member pays 2010% Plan Coinsurance Hospital - Inpatient: After Deductible, Member pays 30% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 30% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Clinical TrialsTrials Preferred Provider Network Out-of-Network

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber Member pays $1,500 2,850 per Member per calendar year for Subscriber only coverage or $5,700 per Family Unit per calendar year Coinsurance Plan Coinsurance: Member pays 2030% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 5,500 per Member or $11,000 per Family Unit per calendar year for Subscriber only coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 2030% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 2030% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 2030% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. After Deductible, Member pays 2030% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 2030% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 2030% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 2030% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 2030% Plan Coinsurance Outpatient Services: After Deductible, Member pays 2030% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber pays $1,500 per calendar year for Subscriber only coverage Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 per calendar year for Subscriber only coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ambulance service is covered only when: • Transport to the nearest facility that can treat your condition • Any other type of transport would put your health or safety at risk. • The service is from a licensed ambulance. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency transportation to the nearest facility that can treat your condition, or air transport to any facilityground Emergency transportation would put your health or safety at risk. After Deductible, Member pays 20% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber Member pays $1,500 500 per Member per calendar year for Subscriber only coverage or $1,000 per Family Unit per calendar year Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 3,000 per Member or $6,000 per Family Unit per calendar year for Subscriber only coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use DisorderChemical Dependency. The first in-person primary care provider office visit claim received and processed per calendar year: No charge, Member pays nothing Office visits: Member pays $20 Copayment for primary care provider services or $40 Copayment for specialty care provider services All other services, including surgical services: After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. The first in-person primary care provider office visit claim received and processed per calendar year: No charge, Member pays nothing Office visits: Member pays $20 Copayment for primary care provider services or $40 Copayment for specialty care provider services All other services, including surgical services: After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. The first in-person primary care provider office visit claim received and processed per calendar year: No charge, Member pays nothing Office visits: Member pays $20 Copayment for primary care provider services or $40 Copayment for specialty care provider services All other services, including surgical services: After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ground or air transport ambulance service is covered only when: • Transport is to any facilitythe nearest facility that can treat your condition. After Deductible, Member pays 20% Plan Coinsurance ambulance coinsurance • Any other type of transport would put your health or safety at risk. • The service is from a licensed ambulance. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency transportation to the nearest facility that can treat your condition, or ground Emergency transportation would put your health or safety at risk. Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWAKFHPWA [, including hospital-to-hospital ground transfers]. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance ambulance coinsurance Hospital-to-hospital ground transfers: After Deductible, No charge; Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: The first in-person primary care provider office visit claim received and processed per calendar year: No charge, Member pays nothing Service delivered via telehealth: No charge; Member pays nothing In-person authorized office visits: Member pays $20 Copayment for primary care provider services or $40 Copayment for specialty care provider services All other services, including surgical services: After Deductible, Member pays 20% Plan Coinsurance In-person self-directed office visits: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber Member pays $1,500 3,000 per Family Unit per calendar year for Subscriber only family coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 7,000 per calendar year for Subscriber only family coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ambulance service is covered only when: • Transport to the nearest facility that can treat your condition • Any other type of transport would put your health or safety at risk. • The service is from a licensed ambulance. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency transportation to the nearest facility that can treat your condition, or air transport to any facilityground Emergency transportation would put your health or safety at risk. After Deductible, Member pays 20% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber pays $1,500 1,850 per calendar year for Subscriber only coverage Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 per calendar year for Subscriber only coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. After Deductible, Member pays 20% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWAKFHPWAO’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Under the Out-of-Network option, Members shall be required to pay any difference between the Out-of-Network Provider’s charge for services and the Allowed Amount, except for Emergency services, including post stabilization and for ancillary services received from an out of network provider in a network facility. For more information about balance billing protections, please visit: xxxxx://xxxxxxx.xxxxxxxxxxxxxxxx.xxx/washington/support/forms and click on the “Billing forms” link. Preferred Provider Network Out-of-Network Annual Deductible Subscriber Member pays $750 per Member per calendar year or $1,500 per Family Unit per calendar year Member pays $1,500 per Member per calendar year for Subscriber only coverage or $3,000 per Family Unit per calendar year Coinsurance Plan Coinsurance: Member pays 2010% of the Allowed Amount Plan Coinsurance: Member pays 30% of the Allowed Amount Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 3,000 per Member or $6,000 per Family Unit per calendar year. No Out-of-pocket Limit; Member pays all cost shares per calendar year The following Out-of-Pocket Expenses apply to the Out-of-Pocket Limit: All Cost Shares for Subscriber only coverage Covered Services The following expenses do not apply to the Out-of-Pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non- Covered Services The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services Not applicable The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Preferred Provider Network Out-of-Network Acupuncture needle treatment, limited to a combined total of 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Exclusions: Herbal supplements; reflexology; any services not within the scope of the practitioner’s licensure Advanced Care at Home Preferred Provider Network Out-of-Network Advanced Care at Home is a personalized, patient-centered program that provides care for patients with certain clinical conditions in their homes, or at another appropriate care location such as a family member’s home or temporary residence. Advanced Care at Home services must be associated with an acute episode in which the member is treated for a brief but severe episode of illness, for conditions that are the result of disease such as, but not exclusive to, congestive heart failure, pneumonia, upper urinary tract infection or cellulitis. The treatment plan may include restorative care associated with the acute episode. The duration of an episode of care (which includes acute and restorative phases) is limited to a total of 30 days. To receive advanced care in the home: • The Member must be referred into the advanced care program by the managing provider at a Network emergency room setting, • Advanced Care at Home requires Preauthorization based on the Member’s health status, treatment plan, and home setting or another appropriate care location within the Service Area, • The clinical condition must meet inpatient Medical Necessity criteria, • The Member must consent to receiving advanced care described in the treatment plan, • The care location, such as the Member’s residence, must be within 30 minutes ground travel time of an emergency department, and • The care location, such as the Member’s residence, must, have cell service. Advanced Care at Home is provided through Medically Home, our Network provider, and will provide the following services in the Member’s home or appropriate care location: • Home visits by RNs, physical therapists, No charge, Member pays nothing Not covered; Member pays 100% of all charges occupational therapists, speech therapists, respiratory therapists, nutritionist, health aides, and other healthcare professionals in accordance with the Advanced Care at Home treatment plan and the provider’s scope of practice and licensure. • Communication devices to allow the Member to contact the medical command center 24 hours a day, 7 days a week. This includes needed communication technology to support reliable connection for communication, and a personal emergency response system alert device to contact the medical command center if the Member is unable to get to a phone. Additional services covered under this benefit include: • The following equipment necessary to ensure that you are monitored appropriately in your home: blood pressure cuff/monitor, pulse oximeter, scale, and thermometer. • Mobile imaging and tests such as X-rays, ultrasounds, and EKGs. • Safety items when Medically Necessary, such as shower stools, raised toilet seats, grabbers, long handled shoehorn, and sock aids. • Meals when Medically Necessary while you are receiving advanced care at home will be provided through our network provider, Medically Home. In addition, cost sharing is waived for the following covered services and items when the services and items are prescribed as part of your Advanced Care at Home treatment plan: • Durable Medical Equipment. • Medical Supplies. • Member transportation to and from Network facilities when Member transport is Medically Necessary will be arranged by Medically Home based on the most appropriate mode of transportation which could be ambulance, cabulance, or otherwise. • Physician Assistant and Nurse Practitioner house calls. • Emergency Department visits associated with this benefit. The cost share is not waived and will apply to any services that are not part of your Advanced Care at Home treatment plan (for example, DME not specified in your Advanced Care at Home treatment plan). For outpatient prescription drug cost shares, see Drugs - Outpatient Prescription. Exclusions: Private Duty Nursing; housekeeping or meal services not part of your Advanced Care at Home treatment plan; any care provided by or for a family member; any other services rendered in the home which are not specified in Allergy Services Preferred Provider Network Out-of-Network Allergy testing. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Ambulance Preferred Provider Network Out-of-Network Emergency ambulance services is covered only when: • Transport to the nearest facility that can treat your condition. • Any other type of transport would put your health or safety at risk • The service is from a licensed ambulance. • The ambulance transports you to a location where you receive covered services. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency transportation to the nearest facility that can treat your condition, or air transport to any facilityground Emergency transportation would put your health or safety at risk. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 10% Plan Coinsurance Non-Emergency ground or air interfacility transfer. Under the Preferred Provider Network option, non- Emergency ground or air interfacility transfer to or from a Preferred Provider Network Facility where you receive covered services when Preauthorized by KFHPWAKFHPWAO. Under the Preferred Provider Network option, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. to- After Deductible, Member pays 2010% Plan Coinsurance Hospital-to-hospital ground transfers: No charge, Member pays nothing After Deductible, Member pays nothing 10% Plan Coinsurance your Advanced Care at Home treatment plan hospital ground transfers when Preauthorized by KFHPWAO. Non-emergent air transportation requires Preauthorization. Cancer Screening and Diagnostic Services Preferred Provider Network Out-of-Network Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA KFHPWAO and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing After Deductible, Member pays 30% Plan Coinsurance Routine Mammography: After Deductible, Member pays 30% Plan Coinsurance Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Circumcision Preferred Provider Network Out-of-Network Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 2010% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 2010% Plan Coinsurance Outpatient Services: After Deductible, Member pays 2010% Plan Coinsurance Within 60 days of birth: No charge; Member pays nothing Hospital - Inpatient: After Deductible, Member pays 30% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 30% Plan Coinsurance Outpatient Services: After Deductible, Member pays 30% Plan Coinsurance Clinical TrialsTrials Preferred Provider Network Out-of-Network

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWAKFHPWAO’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Under the Out-of-Network option, Members shall be required to pay any difference between the Out-of-Network Provider’s charge for services and the Allowed Amount, except for Emergency services and for ancillary services received from an out of network provider in a network facility. For more information about balance billing protections, please visit: https://.xxxxxxx.xxxxxxxxxxxxxxxx.xxx/xxxxxxxxxx/xxxxxxx/xxxxx. Preferred Provider Network Out-of-Network Annual Deductible Subscriber Member pays $750 per Member per calendar year or $1,500 per Family Unit per calendar year for Subscriber only coverage Shared with the Preferred Provider Network Coinsurance Plan Coinsurance: Member pays 2010% of the Allowed Amount Plan Coinsurance: Member pays 30% of the Allowed Amount Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 3,000 per Member or $6,000 per Family Unit per calendar year for Subscriber only coverage Shared with the Preferred Provider Network The following Out-of-pocket Pocket Expenses apply to the Out-of-pocket Pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non- Covered Services The following Out-of-Pocket Expenses apply to the Out-of-Pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-Pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Preferred Provider Network Out-of-Network Acupuncture needle treatment, limited to a combined total of 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Exclusions: Herbal supplements; reflexology; any services not within the scope of the practitioner’s licensure Allergy Services Preferred Provider Network Out-of-Network Allergy testing. After Deductible, Member pays 2010% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 2010% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. Enhanced Benefit: After Deductible, Member pays 205% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Ambulance Preferred Provider Network Out-of-Network Emergency ambulance services is covered only when: • Transport to the nearest facility that can treat your condition. • Any other type of transport would put your health or safety at risk • The service is from a licensed ambulance. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 10% Plan Coinsurance transportation to the nearest facility that can treat your condition, or ground Emergency transportation would put your health or safety at risk. Non-Emergency ground or air interfacility transfer. Under the Preferred Provider Network option, non- Emergency ground or air interfacility transfer to or from a Preferred Provider Network Facility when Preauthorized by KFHPWAKFHPWAO. Under the Preferred Provider Network option, including hospital-to-to- hospital ground transferstransfers when Preauthorized by KFHPWAO. Contact Member Services for Non-emergent air transportation requires Preauthorization. After Deductible, Member pays 2010% Plan Coinsurance Hospital-to-hospital ground transfers: No charge, Member pays nothing After Deductible, Member pays nothing 10% Plan Coinsurance Cancer Screening and Diagnostic Services Preferred Provider Network Out-of-Network Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA KFHPWAO and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing After Deductible, Member pays 30% Plan Coinsurance Routine Mammography: After Deductible, Member pays 30% Plan Coinsurance Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Circumcision Preferred Provider Network Out-of-Network Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 2010% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 2010% Plan Coinsurance Outpatient Services: Hospital - Inpatient: After Deductible, Member pays 30% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 30% Plan Coinsurance Outpatient Services: After Deductible, Member pays 2010% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Clinical TrialsTrials Preferred Provider Network Out-of-Network

Benefits Details. Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Subscriber Member pays $1,500 3,700 per Family Unit per calendar year for Subscriber only family coverage Coinsurance Plan Coinsurance: Member pays 20% Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $3,500 6,500 per calendar year for Subscriber only family coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non-non- Covered Services Pre-existing Condition Waiting Period No pre-existing condition waiting period Acupuncture Acupuncture needle treatment, limited to 12 visits per calendar year without Preauthorization. No visit limit for treatment for Substance Use Disorder. After Deductible, Member pays 20% Plan Coinsurance Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Allergy Services Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance Ambulance Emergency ground or air transport to any facility. After Deductible, Member pays 20% Plan Coinsurance Non-Emergency ground or air interfacility transfer to or from a Network Facility when Preauthorized by KFHPWA, including hospital-to-hospital ground transfers. Contact Member Services for Preauthorization. After Deductible, Member pays 20% Plan Coinsurance Hospital-to-hospital ground transfers: After Deductible, Member pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Xxxxxx Permanente medical centers, at xxx.xx.xxx/xx, or upon request from Member Services. See Preventive Services for additional information. No charge; Member pays nothing Diagnostic laboratory and diagnostic services for cancer. See Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. After Deductible, Member pays 20% Plan Coinsurance Circumcision Circumcision. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member pays 20% Plan Coinsurance Clinical Trials