Kaiser Permanente NW CDHP SBC (2024)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024-12/31/2024 : Wa Health Care Authority Pebb – - Custom High Deductible Health Plan Coverage for: Individual / Family | Plan Type: HDHP (HSA-Qualified) All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see www.kp.org/plandocuments or call 1-800-813-2000 (TTY: 711). For definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call 1-800-813-2000 (TTY: 711) to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount What is the overall deductible? $1,600 Individual / $3,200 Family before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. This plan covers some items and services even if you haven’t yet met the deductible Are there services covered before Yes. Preventive care and services amount. But a copayment or coinsurance may apply. For example, this plan covers you meet your deductible? indicated in chart starting on page 2. certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don’t have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket limit for The out-of-pocket limit is the most you could pay in a year for covered services. If you this plan? $5,100 Individual / $10,200 Family have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, health care this plan the out-of-pocket limit? doesn’t cover, and services indicated Even though you pay these expenses, they don’t count toward the out–of–pocket limit. in chart starting on page 2. This plan uses a provider network. You will pay less if you use a provider in the plan’s Yes. See www.kp.org or call 1-800- network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use a 813-2000 (TTY: 711) for a list of receive a bill from a provider for the difference between the provider’s charge and what network provider? Participating Providers. your plan pays (balance billing).Be aware your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services. 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 1 of 6

Do you need a referral to see a Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but only specialist? specialists. if you have a referral before you see the specialist. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Services You May Need Participating Provider Non-Participating Provider Limitations, Exceptions, & Other Medical Event (You will pay the least) (You will pay the most) Important Information Primary care visit to treat $20 / visit Not covered None an injury or illness If you visit a health Specialist visit $30 / visit Not covered None care provider’s office or clinic You may have to pay for services that aren’t Preventive care/screening/ No charge, deductible does not Not covered preventive. Ask your provider if the services immunization apply. needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, X-ray: 15% coinsurance Not covered None If you have a test blood work) Lab tests: 15% coinsurance Imaging (CT/PET scans, 15% coinsurance Not covered Some services may require prior MRIs) authorization. $15 (retail); $30 (mail order) / Up to a 30-day supply (retail); up to a 90-day Generic drugs prescription Not covered supply (mail order). Subject to formulary If you need drugs guidelines. to treat your illness $40 (retail); $80 (mail order) / Up to a 30-day supply (retail); up to a 90-day or condition Preferred brand drugs prescription Not covered supply (mail order). Subject to formulary More information guidelines. about prescription Up to a 30-day supply (retail); up to a 90-day drug coverage is Non-preferred brand drugs $75 (retail); $150 (mail order) / Not covered supply (mail order). Subject to formulary available at prescription guidelines, when approved through www.kp.org/formulary exception process. 50% coinsurance up to $150 Up to a 30-day supply (retail). Subject to Specialty drugs (retail) / prescription Not covered formulary guidelines, when approved through exception process. If you have Facility fee (e.g., ambulatory 15% coinsurance Not covered Prior authorization required. outpatient surgery surgery center) 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 2 of 6

Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need Participating Provider Non-Participating Provider Important Information (You will pay the least) (You will pay the most) Physician/surgeon fees 15% coinsurance Not covered Prior authorization required. Emergency room care 15% coinsurance 15% coinsurance None If you need Emergency medical 15% coinsurance 15% coinsurance None immediate medical transportation attention Non-Participating Providers covered when Urgent care $40 / visit Not covered temporarily outside the service area: $40 / visit Facility fee (e.g., hospital 15% coinsurance Not covered Prior authorization required. If you have a room) hospital stay Physician/surgeon fees 15% coinsurance Not covered Prior authorization required. If you need mental Outpatient services $20 / visit Not covered None health, behavioral health, or substance Inpatient services 15% coinsurance Not covered Prior authorization required. abuse services Depending on the type of services, a No charge, deductible does not copayment, coinsurance, or deductible may Office visits apply. Not covered apply. Maternity care may include tests and services described elsewhere in the SBC If you are pregnant (i.e., ultrasound). Childbirth/delivery 15% coinsurance Not covered None professional services Childbirth/delivery facility 15% coinsurance Not covered None services Home health care 15% coinsurance Not covered 130 visit limit / year. Prior authorization required. If you need help Outpatient: $30 / visit Outpatient: 60 visit limit / year. Prior recovering or have Rehabilitation services Inpatient: 15% coinsurance Not covered authorization required. other special needs Inpatient: Prior authorization required. Habilitation services $30 / visit Not covered 60 visit limit / year. Prior authorization required. 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 3 of 6

Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need Participating Provider Non-Participating Provider Important Information (You will pay the least) (You will pay the most) Skilled nursing care 15% coinsurance Not covered 150 day limit / year. Prior authorization required. Durable medical 20% coinsurance Not covered Subject to formulary guidelines. Prior equipment authorization required. Hospice services No charge Not covered Prior authorization required. Children’s eye exam No charge for refractive exam, Not covered None If your child needs deductible does not apply. dental or eye care Children’s glasses No charge, deductible does not Not covered Limited to one pair of frames and lenses or apply contact lenses / 12 months. Children’s dental checkups Not covered Not covered None Excluded Services & Other Covered Services Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery • Long-term care • Dental care (Adult and Child) • Non-emergency care when traveling outside • Routine foot care • Infertility treatment the U.S • Weight loss programs • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (12 visit limit / year) • Chiropractic care (12 visit limit / year) • Routine eye care (Adult) • Bariatric surgery • Hearing aids ($3,000 limit / ear / 36 months) 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 4 of 6

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the agencies in the chart below. Kaiser Permanente Member Services 1-800-813-2000 (TTY: 711) or www.kp.org/memberservices Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or www.cciio.cms.gov Oregon Division of Financial Regulation 1-888-877-4894 or www.dfr.oregon.gov 1-800 562 6900 or www.insurance.wa.gov Washington Department of Insurance ‑ ‑ Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-813-2000 (TTY: 711). Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-813-2000 (TTY: 711). Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-813-2000 (TTY: 711). Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-813-2000 (TTY: 711). To see examples of how this plan might cover costs for a sample medical situation, see the next section. 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 5 of 6

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care) ◼ The plan’s overall deductible $3,200 ◼ The plan’s overall deductible $1,600 ◼ The plan’s overall deductible $1,600 ◼ Specialist copayment $30 ◼ Specialist copayment $30 ◼ Specialist copayment $30 ◼ Hospital (facility) coinsurance 15% ◼ Hospital (facility) coinsurance 15% ◼ Hospital (facility) coinsurance 15% ◼ Other (blood work) coinsurance 15% ◼ Other (blood work) coinsurance 15% ◼ Other (x-ray) coinsurance 15% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical Childbirth/Delivery Professional Services disease education) supplies) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $3,200 Deductibles $1,200 Deductibles $1,600 Copayments $10 Copayments $800 Copayments $200 Coinsurance $1,000 Coinsurance $0 Coinsurance $70 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $0 Limits or exclusions $0 The total Peg would pay is $4,270 The total Joe would pay is $2,000 The total Mia would pay is $1,870 [The plan would be responsible for the other costs of these EXAMPLE covered services.] Page 6 of 6