Common use of Pain Management Clause in Contracts

Pain Management. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Manipulative therapy of the spine and extremities when in accordance with KFHPWAO clinical criteria, limited to a combined total of 15 visits per calendar year without Preauthorization. Additional visits are covered with Preauthorization. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAO’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery and associated Hospital Care, including home births and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 Termination of pregnancy. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAO’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require Preauthorization. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAO’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. Members must notify KFHPWAO by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections IV. or V. Inpatient mental health and wellness services, Residential Treatment and partial hospitalization programs must be provided at a hospital or facility that KFHPWAO has approved specifically for the treatment of mental disorders. Preauthorization is required.

Pain Management. Office visits: After Deductible, Member pays 10% Plan Coinsurance $10 Copayment for primary care provider office visits or $30 Copayment for specialty care provider office visits Deductible does not apply to first 5 office visits per calendar year All other services, including surgical services: After Deductible, Member pays 3020% Plan Coinsurance Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 3020% Plan Coinsurance Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to After Deductible, Member pays 20% Plan Coinsurance Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorizationyear. Additional visits are covered with Preauthorization. Office visits: After Deductible, Member pays 10% Plan Coinsurance $10 Copayment for primary care provider office visits or $30 Copayment for specialty care provider office visits Deductible does not apply to first 5 office visits per calendar year All other services, including surgical services: After Deductible, Member pays 3020% Plan Coinsurance Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery Delivery, care for complications of pregnancy and associated Hospital Care, including home births and Medically Necessary supplies for the home birth, and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 1020% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 1020% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced BenefitOffice visits: After Deductible, Member pays 5% Plan Coinsurance Hospital - Inpatient$10 Copayment for primary care provider office visits or $30 Copayment for specialty care provider office visits Deductible does not apply to first 5 office visits per calendar year All other services, including surgical services: After Deductible, Member pays 30% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 30% Plan Coinsurance Outpatient Services: After Deductible, Member pays 3020% Plan Coinsurance Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Hospital - Outpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Outpatient Services: After Deductible, No charge; Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require PreauthorizationPartial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Coverage for voluntary/involuntary Emergency inpatient Hospital - Inpatient: After Deductible, Member is admitted as an inpatient directly from an emergency departmentpays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, any Emergency Member pays 20% Plan Coinsurance Outpatient Services: Office visits: After Deductible, Member pays $10 Copayment for primary care provider or specialty care provider office visits Deductible does not apply to first 5 office visits per calendar year All other services, including surgical services: After Deductible, Member pays 20% Plan Coinsurance Group Sessions: No charge; Member pays nothing psychiatric services Copayment is waived. Coverage is subject to the hospital Emergency services Cost Sharebenefit. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections Section IV. or V. Inpatient Medically Necessary mental health services provided in an outpatient and wellness home health setting. Mental health services are covered when Medically Necessary for treatment of parent-child relational problems for children 5 years of age or younger, neglect or abuse of a child for children five years of age or younger, bereavement for children five years of age or younger, and gender dysphoria unless preempted by federal law. Medically Necessary inpatient mental health services, Residential Treatment and partial hospitalization programs programs, and residential treatment must be provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is requiredChemical dependency services are covered subject to the Chemical Dependency services benefit. Non-Emergency inpatient hospital services, including Residential Treatment and partial hospitalization programs, require Preauthorization.

Pain Management. Office visits: Member pays $30 Copayment for primary care provider office visits or $55 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorizationyear. Additional Office visits: Member pays $30 Copayment for primary care provider office visits are covered with Preauthorization. or $55 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable Hospital - Inpatient: After Deductible, Member pays nothing disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery Delivery, care for complications of pregnancy and associated Hospital Care, including home births and Medically Necessary supplies for the home birth, and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance nothing Outpatient Services: Office visits: Member pays $30 Copayment for primary care provider office visits or $55 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Hospital - Outpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Outpatient Services: After Deductible, No charge; Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to Hospital - Inpatient: After Deductible, Member pays nothing Hospital - Outpatient: After Deductible, Member pays nothing Outpatient Services: Office visits: Member pays $30 Copayment for primary care provider office visits specialty care provider office visits All other services, including surgical services: After Deductible, Member pays nothing Group Sessions: No charge; Member pays nothing outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require PreauthorizationPartial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an Coverage for voluntary/involuntary Emergency inpatient directly from an emergency department, any Emergency psychiatric services Copayment is waived. Coverage is subject to the hospital Emergency services Cost Sharebenefit. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections Section IV. or V. Inpatient Medically Necessary mental health services provided in an outpatient and wellness home health setting. Mental health services are covered when Medically Necessary for treatment of parent-child relational problems for children five years of age or younger, neglect or abuse of a child for children five years of age or younger, bereavement for children five years of age or younger, and gender dysphoria unless preempted by federal law. Medically Necessary inpatient mental health services, Residential Treatment and partial hospitalization programs programs, and residential treatment must be provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is requiredChemical dependency services are covered subject to the Chemical Dependency services benefit. Non-Emergency inpatient hospital services, including Residential Treatment and partial hospitalization programs, require Preauthorization.

Pain Management. Office visits: Member pays $10 Copayment for primary care provider office visits or $20 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorizationyear. Additional Office visits: Member pays $10 Copayment for primary care provider office visits are covered with Preauthorization. or $20 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable Hospital - Inpatient: After Deductible, Member pays nothing disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery Delivery, care for complications of pregnancy and associated Hospital Care, including home births and Medically Necessary supplies for the home birth, and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance nothing Outpatient Services: Office visits: Member pays $10 Copayment for primary care provider office visits or $20 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Hospital - Outpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Outpatient Services: After Deductible, No charge; Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to Hospital - Inpatient: After Deductible, Member pays nothing Hospital - Outpatient: After Deductible, Member pays nothing Outpatient Services: Office visits: Member pays $10 Copayment for primary care provider office visits specialty care provider office visits All other services, including surgical services: After Deductible, Member pays nothing Group Sessions: No charge; Member pays nothing outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require PreauthorizationPartial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an Coverage for voluntary/involuntary Emergency inpatient directly from an emergency department, any Emergency psychiatric services Copayment is waived. Coverage is subject to the hospital Emergency services Cost Sharebenefit. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections Section IV. or V. Inpatient Medically Necessary mental health services provided in an outpatient and wellness home health setting. Mental health services are covered when Medically Necessary for treatment of parent-child relational problems for children five years of age or younger, neglect or abuse of a child for children five years of age or younger, bereavement for children five years of age or younger, and gender dysphoria unless preempted by federal law. Medically Necessary inpatient mental health services, Residential Treatment and partial hospitalization programs programs, and residential treatment must be provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is requiredChemical dependency services are covered subject to the Chemical Dependency services benefit. Non-Emergency inpatient hospital services, including Residential Treatment and partial hospitalization programs, require Preauthorization.

Pain Management. After DeductibleTo receive benefits for the administration of select infusion medications in the home setting, the drugs must be obtained through KFHPWAO’s preferred specialty pharmacy and administered by a provider we identify. For a list of these specialty drugs or for more information about KFHPWAO’s specialty pharmacy network, please go to the KFHPWAO website at xxx.xx.xxx/xx/xxxxxxxxx or contact Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Associated infused medicationsServices. After Deductible, Member pays 10% Plan Coinsurance Home setting: Not covered; Member pays 100% of all charges Outpatient setting: After Deductible, Member pays 30% Plan Coinsurance Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by 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. After Deductible, Member pays 10% Plan Coinsurance Urine Drug Screening: No charge, Member pays nothing. Limited to 2 tests per calendar year. Benefits are applied in the order claims are received and processed. After allowance: After Deductible, Member After Deductible, Member pays 30% Plan Coinsurance request from Member Services. pays 10% Plan Coinsurance Manipulative therapy of the spine and extremities when in accordance with KFHPWAO clinical criteria, limited to a combined total of 15 visits per calendar year without Preauthorization. Additional visits are covered with Preauthorization. Rehabilitation services, such as massage or physical therapy, provided with manipulations is covered under the Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy section. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAO’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery and associated Hospital Care, including home births and birthing centers. Home births are considered outpatient services. Donor breast milk will be covered during the inpatient hospital stay when Medically Necessary, provided through a milk bank and ordered by a licensed Provider or board- certified lactation consultant. Members must notify KFHPWAO by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 Termination of pregnancy. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAO’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require Preauthorization. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAO’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 is waived. Coverage is subject to the hospital services Cost Share. Members must notify KFHPWAO by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections IV. or V. Inpatient mental health and wellness services, Residential Treatment and partial hospitalization programs must be provided at a hospital or facility that KFHPWAO has approved specifically for the treatment of mental disorders. Preauthorization is required. Outpatient specialty services, including rTMS, ECT, and Esketamine require Preauthorization. Routine outpatient therapy and psychiatry services with contracted network providers do not require Preauthorization.

Pain Management. Office visits: Member pays $5 Copayment for primary care provider office visits or $10 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorizationyear. Additional Office visits: Member pays $5 Copayment for primary care provider office visits are covered with Preauthorization. or $10 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable Hospital - Inpatient: After Deductible, Member pays nothing disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery Delivery, care for complications of pregnancy and associated Hospital Care, including home births and Medically Necessary supplies for the home birth, and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance nothing Outpatient Services: Office visits: Member pays $5 Copayment for primary care provider office visits or $10 Copayment for specialty care provider office visits All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Hospital - Outpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Outpatient Services: After Deductible, No charge; Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to Hospital - Inpatient: After Deductible, Member pays nothing Hospital - Outpatient: After Deductible, Member pays nothing Outpatient Services: Office visits: Member pays $5 Copayment for primary care provider office visits specialty care provider office visits All other services, including surgical services: After Deductible, Member pays nothing Group Sessions: No charge; Member pays nothing outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require PreauthorizationPartial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an Coverage for voluntary/involuntary Emergency inpatient directly from an emergency department, any Emergency psychiatric services Copayment is waived. Coverage is subject to the hospital Emergency services Cost Sharebenefit. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections Section IV. or V. Inpatient Medically Necessary mental health services provided in an outpatient and wellness home health setting. Mental health services are covered when Medically Necessary for treatment of parent-child relational problems for children five years of age or younger, neglect or abuse of a child for children five years of age or younger, bereavement for children five years of age or younger, and gender dysphoria unless preempted by federal law. Medically Necessary inpatient mental health services, Residential Treatment and partial hospitalization programs programs, and residential treatment must be provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is requiredChemical dependency services are covered subject to the Chemical Dependency services benefit. Non-Emergency inpatient hospital services, including Residential Treatment and partial hospitalization programs, require Preauthorization.

Pain Management. After Deductible, Member pays 1020% Plan Coinsurance For first 3 primary care provider office visits per calendar year, Member pays $40 Copayment. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 3020% Plan Coinsurance Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 3020% Plan Coinsurance Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 3020% Plan Coinsurance Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorization. Additional visits are covered with Preauthorizationyear. After Deductible, Member pays 1020% Plan Coinsurance For first 3 primary care provider office visits per calendar year, Member pays $40 Copayment. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 3020% Plan Coinsurance DRAFT Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery Delivery, care for complications of pregnancy and associated Hospital Care, including home births and Medically Necessary supplies for the home birth, and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 1020% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 1020% Plan Coinsurance Outpatient Services: After Deductible, Member pays 1020% Plan Coinsurance Enhanced BenefitFor first 3 primary care provider office visits per calendar year, Member pays $40 Copayment. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 5% 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 3020% Plan Coinsurance Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Hospital - Outpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Outpatient Services: After Deductible, No charge; Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member DRAFT prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require PreauthorizationPartial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an Coverage for voluntary/involuntary Emergency inpatient directly from an emergency department, any Emergency psychiatric services Copayment is waived. Coverage is subject to the hospital Emergency services Cost Sharebenefit. Members must notify KFHPWAO KFHPWA by way of the KFHPWA Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatientexcluded under Section IV. or V. Medically Necessary mental health services provided in an outpatient and home health setting. Mental health services are covered when Medically Necessary for treatment of parent-child relational problems for children 5 years of age or younger, neglect or abuse of a child for children five years of age or younger, bereavement for children five years of age or younger, and gender dysphoria unless preempted by federal law. Medically Necessary inpatient mental health services, partial hospitalization programs, and residential treatment must be pays 20% Plan Coinsurance For first 3 primary care provider office visits per calendar year, no charge; Member pays nothing. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 1020% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections IV. or V. Inpatient mental health and wellness services, Residential Treatment and partial hospitalization programs must be DRAFT provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is requiredChemical dependency services are covered subject to the Chemical Dependency services benefit. Non-Emergency inpatient hospital services, including Residential Treatment and partial hospitalization programs, require Preauthorization.

Pain Management. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Associated infused medications. After Deductible, No charge; Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, No charge; Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance nothing Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorizationyear. Additional visits are covered with PreauthorizationPreauthorization is not required. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 30% Plan Coinsurance $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery and associated Hospital Care, including home births and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance $100 Copayment per day up to $300 per admission Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance $100 Copayment Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance $100 Copayment per day up to $300 per admission Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance $100 Copayment Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 $10 Copayment for primary care provider services or $20 Copayment for specialty care provider services Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and prescriptions are covered the same as for any other condition. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require Preauthorization. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an inpatient directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost Share. Coverage for services incurred at non-Network Facilities shall exclude any charges that would otherwise be excluded for hospitalization within a Network Facility. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections IV. or V. Inpatient mental health and wellness services, Residential Treatment and partial hospitalization programs must be provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is required.Chemical dependency services are covered subject to the Chemical Dependency services benefit. Hospital - Inpatient: After Deductible, Member pays $100 Copayment per day up to $300 per admission Hospital - Outpatient: After Deductible, Member pays $100 Copayment Outpatient Services: After Deductible, Member pays $10 Copayment for primary care provider services Group Visits: No charge; Member pays nothing

Pain Management. After Deductible, Member pays 1020% Plan Coinsurance For first 3 primary care provider office visits per calendar year, Member pays $40 Copayment. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 3020% Plan Coinsurance Associated infused medications. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 3020% Plan Coinsurance Nuclear medicine, radiology, ultrasound and laboratory services, including high end radiology imaging services such as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Services received as part of an emergency visit are covered as Emergency Services. Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWAO 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. After Deductible, Member pays 10% Plan Coinsurance After Deductible, Member pays 3020% Plan Coinsurance Manipulative therapy of the spine and extremities when in accordance with KFHPWAO KFHPWA clinical criteria, limited to a combined total of 15 10 visits per calendar year without Preauthorization. Additional visits are covered with Preauthorizationyear. After Deductible, Member pays 1020% Plan Coinsurance For first 3 primary care provider office visits per calendar year, Member pays $40 Copayment. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 3020% Plan Coinsurance Maternity care and pregnancy services, including care for complications of pregnancy, in utero treatment for the fetus, prenatal testing for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are covered for all female Members members including dependent daughters. Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth when Medically Necessary as determined by KFHPWAOKFHPWA’s medical director and in accordance with Board of Health standards for screening and diagnostic tests during pregnancy. Delivery Delivery, care for complications of pregnancy and associated Hospital Care, including home births and Medically Necessary supplies for the home birth, and birthing centers. Home births are considered outpatient services. Members must notify KFHPWAO KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Member’s physician, in consultation with the Member, will determine the Member’s length of inpatient stay following delivery. Hospital - Inpatient: After Deductible, Member pays 1020% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 1020% Plan Coinsurance Outpatient Services: After Deductible, Member pays 1020% Plan Coinsurance Enhanced BenefitFor first 3 primary care provider office visits per calendar year, Member pays $40 Copayment. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 5% 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 3020% Plan Coinsurance Termination of pregnancy. Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Hospital - Outpatient: After Deductible, No charge; Member pays 10% Plan Coinsurance nothing Outpatient Services: After Deductible, No charge; Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% 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 nothing Mental health and wellness services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWAOKFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health and wellness services including medical management and Hospital - Inpatient: After Deductible, Member pays 20% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 20% Plan Coinsurance Outpatient Services: After Deductible, Member prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a developmental disability for which there is evidence that ABA therapy is effective, as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. ABA therapy services require PreauthorizationPartial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWAOKFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If a Member is admitted as an Coverage for voluntary/involuntary Emergency inpatient directly from an emergency department, any Emergency psychiatric services Copayment is waived. Coverage is subject to the hospital Emergency services Cost Sharebenefit. Members must notify KFHPWAO KFHPWA by way of the KFHPWA Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Mental health and wellness services rendered to treat mental disorders are covered. Mental Disorders means mental disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, except as otherwise excluded under Sections IV. or V. Mental Health and Wellness Services means Medically Necessary outpatient services, Residential Treatment, partial hospitalization program, and inpatient services provided by a licensed facility or licensed providers; including advanced practice psychiatric nurses, mental health and wellness counselors, marriage and family therapists and social workers, except as otherwise Hospital - Inpatientexcluded under Section IV. or V. Medically Necessary mental health services provided in an outpatient and home health setting. Mental health services are covered when Medically Necessary for treatment of parent-child relational problems for children 5 years of age or younger, neglect or abuse of a child for children five years of age or younger, bereavement for children five years of age or younger, and gender dysphoria unless preempted by federal law. Medically Necessary inpatient mental health services, partial hospitalization programs, and residential treatment must be pays 20% Plan Coinsurance For first 3 primary care provider office visits per calendar year, no charge; Member pays nothing. Deductible does not apply Following these 3 office visits: After Deductible, Member pays 1020% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: After Deductible, Member pays 10% Plan Coinsurance Enhanced Benefit: After Deductible, Member pays 5% Plan Coinsurance Group Visits: 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 excluded under Sections IV. or V. Inpatient mental health and wellness services, Residential Treatment and partial hospitalization programs must be provided at a hospital or facility that KFHPWAO KFHPWA has approved specifically for the treatment of mental disorders. Preauthorization is requiredChemical dependency services are covered subject to the Chemical Dependency services benefit. Non-Emergency inpatient hospital services, including Residential Treatment and partial hospitalization programs, require Preauthorization.