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 Member pays $3,000 per Family Unit per calendar year for family coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $7,000 per calendar year for family coverage Pre-existing Condition Waiting Period No pre-existing condition waiting period 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 Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance 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 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. 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

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 Member Subscriber pays $3,000 per Family Unit 1,500 per calendar year for family Subscriber only coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $7,000 3,500 per calendar year for family Subscriber only coverage Pre-existing Condition Waiting Period No pre-existing condition waiting period 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 Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance 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 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. 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

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 Member pays $3,000 1,000 per Member per calendar year or $2,000 per Family Unit per calendar year for family coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $7,000 3,000 per Member or $6,000 per Family Unit per calendar year for family coverage Pre-existing Condition Waiting Period No pre-existing condition waiting period 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 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 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 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. 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

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 Member Subscriber pays $3,000 per Family Unit 1,850 per calendar year for family Subscriber only coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $7,000 3,500 per calendar year for family Subscriber only coverage Pre-existing Condition Waiting Period No pre-existing condition waiting period 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 Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance 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 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. 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

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 Member pays $3,000 3,700 per Family Unit per calendar year for family coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $7,000 6,500 per calendar year for family coverage Pre-existing Condition Waiting Period No pre-existing condition waiting period 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 Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance 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 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. 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

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 Member pays $3,000 per Family Unit per calendar year for family coverage Until the total family annual Deductible is met, benefits will not be provided for any family member Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $7,000 per calendar year for family coverage Pre-existing Condition Waiting Period No pre-existing condition waiting period 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 Allergy testing. After Deductible, Member pays 20% Plan Coinsurance Allergy serum and injections. After Deductible, Member pays 20% Plan Coinsurance 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 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. 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