Kaiser Permanente WA Value EOC (2024)

Kaiser Foundation Health Plan of Washington A nonprofit health maintenance organization 2024 Evidence of Coverage PEBB Value Plan for Active Employees PEBB_VA_2024 1

Important Notice Under Federal Health Care Reform Kaiser Foundation Health Plan of Washington (“KFHPWA”) recommends each Enrollee choose a Network Personal Physician. This decision is important since the designated Network Personal Physician provides or arranges for most of the Enrollee’s health care. The Enrollee has the right to designate any Network Personal Physician who participates in one of the KFHPWA networks and who is available to accept the Enrollee or the Enrollee’s family members. For information on how to select a Network Personal Physician, and for a list of the participating Network Personal Physicians, please call Kaiser Permanente Member Services at (206) 630-0107 in the Seattle area, or toll-free in Washington, 1-866-648-192. For children, the Enrollee may designate a pediatrician as the primary care provider. The Enrollee does not need Preauthorization from KFHPWA or from any other person (including a Network Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals who specialize in obstetrics or gynecology, please call the Kaiser Permanente Member Services at (206) 630-0107 in the Seattle area, or toll-free in Washington, 1-866-648-192. Women’s health and cancer rights If the Enrollee is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the mastectomy, the Enrollee will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses. • Treatment of physical complications of all stages of mastectomy, including lymphedemas. These services will be provided in consultation with the Enrollee and the attending physician and will be subject to the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC). Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours). Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. For More Information KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Enrollees on request. Please call Kaiser Permanente Member Services at (206) 630-0107 in the Seattle area, or toll-free in Washington, 1- 866-648-1928. For the deaf and hearing-impaired use Washington state’s relay line at 800-833-6388 or 711 for benefits questions PEBB_VA_2024 2

Table of Contents Table of Contents ......................................................................................................................................................... 3 I. Introduction ................................................................................................................................................... 6 II. How Covered Services Work ........................................................................................................................ 6 A. Accessing Care. ........................................................................................................................................ 6 B. Administration of the EOC. ..................................................................................................................... 9 C. Assignment. .............................................................................................................................................. 9 D. Confidentiality.......................................................................................................................................... 9 E. Modification of the EOC. ......................................................................................................................... 9 F. Nondiscrimination. ................................................................................................................................... 9 G. Preauthorization. .................................................................................................................................... 10 H. Recommended Treatment. ..................................................................................................................... 10 I. Second Opinions. ................................................................................................................................... 10 J. Unusual Circumstances. ......................................................................................................................... 10 K. Utilization Management. ........................................................................................................................ 11 III. Financial Responsibilities ........................................................................................................................... 11 A. Premium. ................................................................................................................................................ 11 B. Financial Responsibilities for Covered Services. ................................................................................... 11 C. Financial Responsibilities for Non-Covered Services. ........................................................................... 11 IV. Benefits Details ............................................................................................................................................ 12 Annual Deductible ......................................................................................................................................... 12 Prescription Drug Deductible ........................................................................................................................ 12 Coinsurance ................................................................................................................................................... 12 Lifetime Maximum ....................................................................................................................................... 12 Medical Out-of-pocket Limit ........................................................................................................................ 12 Prescription Drug Out-of-pocket Limit ......................................................................................................... 12 Pre-existing Condition Waiting Period ......................................................................................................... 12 Acupuncture .................................................................................................................................................. 13 Advanced Care at Home ................................................................................................................................ 13 Allergy Services ............................................................................................................................................ 15 Ambulance .................................................................................................................................................... 15 Cancer Screening and Diagnostic Services ................................................................................................... 15 Circumcision ................................................................................................................................................. 16 Clinical Trials ................................................................................................................................................ 16 Dental Services and Dental Anesthesia ......................................................................................................... 16 Devices, Equipment and Supplies (for home use) ......................................................................................... 17 Diabetic Education, Equipment and Pharmacy Supplies .............................................................................. 18 Dialysis (Home and Outpatient) .................................................................................................................... 19 Drugs - Outpatient Prescription ..................................................................................................................... 20 Emergency Services ...................................................................................................................................... 24 Gender Health Services ................................................................................................................................. 24 Hearing Examinations and Hearing Aids ...................................................................................................... 25 Home Health Care ......................................................................................................................................... 25 Hospice .......................................................................................................................................................... 26 Hospital - Inpatient and Outpatient ............................................................................................................... 27 PEBB_VA_2024 3

Infertility (including sterility) ........................................................................................................................ 28 Infusion Therapy ......................................................................................................................................... 28 Laboratory and Radiology ............................................................................................................................. 29 Manipulative Therapy ................................................................................................................................... 29 Massage Therapy ........................................................................................................................................... 29 Maternity and Pregnancy ............................................................................................................................... 30 Mental Health and Wellness .......................................................................................................................... 30 Naturopathy ................................................................................................................................................... 31 Newborn Services ......................................................................................................................................... 32 Nutritional Counseling .................................................................................................................................. 32 Nutritional Therapy ....................................................................................................................................... 32 Obesity Related Surgical Services................................................................................................................. 33 On the Job Injuries or Illnesses ..................................................................................................................... 33 Oncology ....................................................................................................................................................... 34 Optical (vision) .............................................................................................................................................. 34 Oral Surgery .................................................................................................................................................. 36 Outpatient Services ....................................................................................................................................... 36 Plastic and Reconstructive Surgery ............................................................................................................... 36 Podiatry ......................................................................................................................................................... 37 Preventive Services ....................................................................................................................................... 37 Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy .................................................................................. 38 Reproductive Health ...................................................................................................................................... 40 Sexual Dysfunction ....................................................................................................................................... 40 Skilled Nursing Facility................................................................................................................................. 41 Sterilization ................................................................................................................................................... 41 Substance Use Disorder................................................................................................................................. 41 Telehealth Services ....................................................................................................................................... 43 Temporomandibular Joint (TMJ) .................................................................................................................. 44 Tobacco Cessation ......................................................................................................................................... 44 Transplants .................................................................................................................................................... 45 Urgent Care ................................................................................................................................................... 46 V. General Exclusions ...................................................................................................................................... 46 VI. Eligibility, Enrollment and Termination ................................................................................................... 48 A. Eligibility. .............................................................................................................................................. 48 B. Enrollment for subscribers and dependents. ........................................................................................... 49 C. Medicare Eligibility and Enrollment. ..................................................................................................... 52 D. When Medical Coverage Begins. ........................................................................................................... 52 E. Making changes ..................................................................................................................................... 53 F. When medical coverage ends ................................................................................................................. 59 G. General provisions for eligibility and enrollment .................................................................................. 61 H. Appeal rights .......................................................................................................................................... 62 I. Relationship to law and regulations ....................................................................................................... 62 VII. Grievances .................................................................................................................................................... 62 VIII. Appeals ......................................................................................................................................................... 63 PEBB_VA_2024 4

IX. Claims ........................................................................................................................................................... 64 X. Coordination of Benefits ............................................................................................................................. 65 Definitions. .................................................................................................................................................... 65 Order of Benefit Determination Rules........................................................................................................... 67 Effect on the Benefits of this Plan. ................................................................................................................ 68 Right to Receive and Release Needed Information. ...................................................................................... 68 Facility of Payment. ...................................................................................................................................... 68 Right of Recovery. ........................................................................................................................................ 68 Effect of Medicare. ........................................................................................................................................ 69 XI. Subrogation and Reimbursement Rights .................................................................................................. 69 XII. Definitions .................................................................................................................................................... 70 PEBB_VA_2024 5

I. Introduction This EOC is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between Kaiser Foundation Health Plan of Washington (“KFHPWA”) and the Group. The benefits were approved by the Group who contracts with KFHPWA for health care coverage. This EOC is not the Group medical coverage agreement itself. In the event of a conflict between the Group medical coverage agreement and the EOC, the EOC language will govern. The provisions of the EOC must be considered together to fully understand the benefits available under the EOC. Words with special meaning are capitalized and are defined in Section XII. Contact Kaiser Permanente Member Services at 206-630-0107 or toll-free 1-866-648-1928 for the deaf and hearing- impaired use Washington state’s relay line at 800-833-6388 or 711 for benefits questions. II. How Covered Services Work A. Accessing Care. 1. Enrollees are entitled to Covered Services from the following: Your Provider Network is KFHPWA’s Core Network (Network). Enrollees are entitled to Covered Services only at Network Facilities and from Network Providers, except for Emergency services and care pursuant to a Preauthorization. Benefits under this EOC will not be denied for any health care service performed by a registered nurse licensed to practice under chapter 18.88 RCW, if first, the service performed was within the lawful scope of such nurse’s license, and second, this EOC would have provided benefit if such service had been performed by a Doctor of Medicine licensed to practice under chapter 18.71 RCW. A listing of Core Network Personal Physicians, specialists, women’s health care providers and KFHPWA- designated Specialists is available by contacting Member Services or accessing the KFHPWA website at www.kp.org/wa. Information available online includes each physician’s location, education, credentials, and specialties. KFHPWA also utilizes Health Care Benefit Managers for certain services. To see a list of Health Care Benefit Managers, go to https://healthy.kaiserpermanente.org/washington/support/forms and click on the “Evidence of coverage” link. Receiving Care in another Kaiser Foundation Health Plan Service Area If you are visiting in the service area of another Kaiser Permanente region, visiting member services may be available from designated providers in that region if the services would have been covered under this EOC. Visiting member services are subject to the provisions set forth in this EOC including, but not limited to, Preauthorization and cost sharing. For more information about receiving visiting member services in other Kaiser Permanente regional health plan service areas, including provider and facility locations, please call Kaiser Permanente Member Services at (206) 630-0107 in the Seattle area, or toll-free in Washington, 1-866-648-1928. Information is also available online at https://wa.kaiserpermanente.org/html/public/services/traveling. KFHPWA will not directly or indirectly prohibit Enrollees from freely contracting at any time to obtain health care services from Non-Network Providers and Non-Network Facilities outside the Plan. However, if you choose to receive services from Non-Network Providers and Non-Network Facilities except as otherwise specifically provided in this EOC, those services will not be covered under this EOC, and you will be responsible for the full price of the services. Any amounts you pay for non-covered services will not count toward your Out-of-Pocket Limit. 2. Primary Care Provider Services. KFHPWA recommends that Enrollees select a Network Personal Physician when enrolling. One personal physician may be selected for an entire family, or a different personal physician may be selected for each PEBB_VA_2024 6

family member. For information on how to select or change Network Personal Physicians, and for a list of participating personal physicians, call the Kaiser Permanente Member Services at (206) 630-0107 in the Seattle area, or toll-free in Washington at 1-866-648-1928 or by accessing the KFHPWA website at www.kp.org/wa. The change will be made within 24 hours of the receipt of the request if the selected physician’s caseload permits. If a personal physician accepting new Enrollees is not available in your area, contact the Kaiser Permanente Member Services, who will ensure you have access to a personal physician by contacting a physician’s office to request they accept new Enrollees. To find a personal physician, contact Member Services or access the KFHPWA website at www.kp.org/wa to view physician profiles. Online you will find information on each physician’s location, education, credentials, and specialties. For your personal physician, choose from these specialties: • Family medicine • Adult medicine/internal medicine • Pediatrics/adolescent medicine (for children up to 18) Be sure to check that the physician you are considering is accepting new patients. If your choice does not feel right after a few visits, you can change personal physician at any time, for any reason. If you don’t choose a physician when you first become a KFHPWA Enrollee, we will match you with a physician to make sure you have one assigned to you if you get sick or injured. In the case that the Enrollee’s personal physician no longer participates in KFHPWA’s network, the Enrollee will be provided access to the personal physician for up to 60 days following a written notice offering the Enrollee a selection of new personal physicians from which to choose. 3. Specialty Care Provider Services. Unless otherwise indicated in Section II. or Section IV., Preauthorization is required for specialty care and specialists that are not KFHPWA-designated Specialists and are not providing care at facilities owned and operated by Kaiser Permanente. KFHPWA-designated Specialist. Preauthorization is not required for services with KFHPWA-designated Specialists at facilities owned and operated by Kaiser Permanente. To access a KFHPWA-designated Specialist, consult your KFHPWA personal physician. For a list of KFHPWA-designated Specialists, contact Member Services or view the Provider Directory located at www.kp.org/wa. The following specialty care areas are available from KFHPWA-designated Specialists: allergy, audiology, cardiology, chiropractic/manipulative therapy, dermatology, gastroenterology, general surgery, hospice, mental health and wellness, nephrology, neurology, obstetrics and gynecology, occupational medicine, oncology/hematology, ophthalmology, optometry, orthopedics, otolaryngology (ear, nose and throat), physical therapy, smoking cessation, speech/language and learning services, substance use disorder and urology. Specialty Care Provider Copayment. The following providers are subject to the specialty Copayment level: allergy and immunology, anesthesiology, audiology, cardiology (pediatric and cardiovascular disease), critical care medicine, dentistry, dermatology, endocrinology, enterostomal therapy, gastroenterology, genetics, hepatology, infectious disease, massage therapy, neonatal-perinatal medicine, nephrology, neurology, nutrition, occupational medicine, occupational therapy, hematology/oncology, oncology pharmacist, ophthalmology, orthopedics, ENT/otolaryngology, pain management, pathology, physiatry (physical medicine), physical therapy, podiatry, pulmonary medicine/disease, radiology (nuclear medicine, radiation therapy), respiratory therapy, rheumatology, speech therapy, sports medicine, general surgery and urology. 4. Hospital Services. Non-Emergency inpatient hospital services require Preauthorization. Refer to Section IV. for more information about hospital services. PEBB_VA_2024 7

5. Emergency Services. Emergency services at a Network Facility or non-Network Facility are covered. Enrollees must notify KFHPWA by way of the Hospital notification line (1-888-457-9516 as noted on your member identification card) within 24 hours of any admission, or as soon thereafter as medically possible. Coverage for Emergency services at a non-Network Facility is limited to the Allowed Amount. Refer to Section IV. for more information about Emergency services. Enrollees are covered for Emergency care and Medically Necessary urgent care anywhere in the world. If you think you are experiencing an emergency, go immediately to the nearest emergency care facility or call 911. Go to the closest urgent care center for an illness or injury that requires prompt medical attention but is not an emergency. Examples include, but are not limited to minor injuries, wounds, and cuts needing stiches; minor breathing issues; minor stomach pain. If you are unsure whether urgent care is your best option, call the consulting nurse helpline for advice at 1-800-297-6877 or 206-630-2244. If you need Emergency care while traveling and are admitted to a non-network hospital, you or a family member must notify us within 24 hours after care begins, or as soon as is reasonably possible. Call the notification line listed on the back of your KFHPWA Member ID card to help make sure your claim is accepted. Keep receipts and other paperwork from non-network care. You’ll need to submit them with any claims for reimbursement after returning from travel. Access to non-Emergency care across the Core network service area: your Plan provides access to all providers in the Core Network, including many physicians and services at Kaiser Permanente medical facilities and Core Network facilities across the state. Find links to providers at www.kp.org/wa/directory or contact Member Services at 1-866-648-1928 for assistance. 6. Urgent Care. Inside the KFHPWA Service Area, urgent care is covered at a Kaiser Permanente medical center, Kaiser Permanente urgent care center or Network Provider’s office. Outside the KFHPWA Service Area, urgent care is covered at any medical facility. Refer to Section IV. for more information about urgent care. For urgent care during office hours, you can call your personal physician’s office first to see if you can get a same-day appointment. If a physician is not available or it is after office hours, you may speak with a licensed care provider anytime at 1-800-297-6877 or 206-630-2244. You may also check www.kp.org/wa/directory or call Member Services to find the nearest urgent care facility in your network. 7. Women’s Health Care Direct Access Providers. Female Enrollees may see a general and family practitioner, physician’s assistant, gynecologist, certified nurse midwife, licensed midwife, doctor of osteopathy, pediatrician, obstetrician or advance registered nurse practitioner who is unrestricted in your KFHPWA Network to provide women’s health care services directly, without Preauthorization, for Medically Necessary maternity care, covered reproductive health services, preventive services (well care) and general examinations, gynecological care and follow-up visits for the above services. Women’s health care services are covered as if the Enrollee’s Network Personal Physician had been consulted, subject to any applicable Cost Shares. If the Enrollee’s women’s health care provider diagnoses a condition that requires other specialists or hospitalization, the Enrollee or her chosen provider must obtain Preauthorization in accordance with applicable KFHPWA requirements. For a list of KFHPWA providers, contact Member Services or view the Provider Directory located at www.kp.org/wa. 8. Travel Advisory Services. Our Travel Advisory Service offers recommendations tailored to your travel outside the United States. Nurses certified in travel health will advise you on any vaccines or medications you need based on your destination, activities, and medical history. The consultation is not a covered benefit and there is a fee for a KFHPWA Enrollee using the service for the first time. Travel-related vaccinations and medications are usually not covered. Visit www.kp.org/wa/travel-service for more details. PEBB_VA_2024 8

9. Process for Medical Necessity Determination. Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Enrollees will be notified in writing when a determination has been made. First Level Review: First level reviews are performed or overseen by appropriate clinical staff using KFHPWA approved clinical review criteria. Data sources for the review include, but are not limited to, referral forms, admission request forms, the Enrollee’s medical record, and consultation with qualified health professionals and multidisciplinary health care team members. The clinical information used in the review may include treatment summaries, problem lists, specialty evaluations, laboratory and x-ray results, and rehabilitation service documentation. The Enrollee or legal surrogate may be contacted for information. Coordination of care interventions are initiated as they are identified. The reviewer consults with the health care team when more clarity is needed to make an informed medical necessity decision. The reviewer may consult with a board-certified consultative specialist and such consultations will be documented in the review text. If the requested service appears to be inappropriate based on application of the review criteria, the first level reviewer requests second level review by a physician or designated health care professional. Second Level (Practitioner) Review: The practitioner reviews the treatment plan and discusses, when appropriate, case circumstances and management options with the attending (or referring) physician. The reviewer consults with the health care team when more clarity is needed to make an informed coverage decision. The reviewer may consult with board certified physicians from appropriate specialty areas to assist in making determinations of coverage and/or appropriateness. All such consultations will be documented in the review text. If the reviewer determines that the admission, continued stay or service requested is not a covered service, a notice of non- coverage is issued. Only a physician, behavioral health practitioner (such as a psychiatrist, doctoral-level clinical psychologist, certified addiction medicine specialist), dentist or pharmacist who has the clinical expertise appropriate to the request under review with an unrestricted license may deny coverage based on Medical Necessity. B. Administration of the EOC. KFHPWA may adopt reasonable policies and procedures to administer the EOC. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. C. Assignment. The Enrollee may not assign this EOC or any of the rights, interests, claims for money due, benefits, or obligations here under without prior written consent. D. Confidentiality. KFHPWA is required by federal and state law to maintain the privacy of Enrollee personal and health information. KFHPWA is required to provide notice of how KFHPWA may use and disclose personal and health information held by KFHPWA. The Notice of Privacy Practices is distributed to Enrollees and is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. E. Modification of the EOC. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the EOC, convey or void any coverage, increase or reduce any benefits under the EOC or be used in the prosecution or defense of a claim under the EOC. F. Nondiscrimination. KFHPWA does not discriminate on the basis of physical or mental disabilities in its employment practices and services. KFHPWA will not refuse to enroll or terminate an Enrollee’s coverage and will not deny care on the basis of age, sex, sexual orientation, gender identity, race, religion, occupation or health status. PEBB_VA_2024 9

G. Preauthorization. Refer to Section IV. or call Member Services for more information regarding which services, equipment and facility types KFHPWA requires Preauthorization. Failure to obtain Preauthorization when required may result in denial of coverage for those services; and the Enrollee may be responsible for the cost of these non-Covered services. Enrollees may contact Member Services to request Preauthorization. Preauthorization requests, including prescription requests, are reviewed and approved based on Medical Necessity, eligibility and benefits. KFHPWA will generally process Preauthorization requests and provide notification for benefits within the following timeframes: • For electronic standard requests – within three calendar days, excluding holidays. o If insufficient information has been provided, a request for additional information will be made within one calendar day. • For electronic expedited prior authorization requests – within one calendar day o If insufficient information has been provided, a request for additional information will be made within one calendar day. • For nonelectronic standard requests – within five calendar days o If insufficient information has been provided, a request for additional information will be made within five calendar days. • For nonelectronic expedited requests - within two calendar days o If insufficient information has been provided, a request for additional information will be made within one calendar day. H. Recommended Treatment. KFHPWA’s medical director will determine the necessity, nature and extent of treatment to be covered in each individual case and the judgment will be made in good faith. Enrollees have the right to appeal coverage decisions (see Section VIII.). Enrollees have the right to participate in decisions regarding their health care. An Enrollee may refuse any recommended services to the extent permitted by law. Enrollees who obtain care not recommended by KFHPWA’s medical director do so with the full understanding that KFHPWA has no obligation for the cost, or liability for the outcome, of such care. New and emerging medical technologies are evaluated on an ongoing basis by the following committees – the Interregional New Technologies Committee, Medical Technology Assessment Committee, Medical Policy Committee, and Pharmacy and Therapeutics Committee. These physician evaluators consider the new technology’s benefits, whether it has been proven safe and effective, and under what conditions its use would be appropriate. The recommendations of these committees inform what is covered on KFHPWA health plans. I. Second Opinions. The Enrollee may access a second opinion from a Network Provider regarding a medical diagnosis or treatment plan. The Enrollee may request Preauthorization or may visit a KFHPWA-designated Specialist for a second opinion. When requested or indicated, second opinions are provided by Network Providers and are covered with Preauthorization, or when obtained from a KFHPWA-designated Specialist. Coverage is determined by the Enrollee's EOC; therefore, coverage for the second opinion does not imply that the services or treatments recommended will be covered. Preauthorization for a second opinion does not imply that KFHPWA will authorize the Enrollee to return to the physician providing the second opinion for any additional treatment. Services, drugs and devices prescribed or recommended as a result of the consultation are not covered unless included as covered under the EOC. J. Unusual Circumstances. In the event of unusual circumstances such as a major disaster, epidemic, military action, civil disorder, labor disputes or similar causes, KFHPWA will not be liable for administering coverage beyond the limitations of available personnel and facilities. In the event of unusual circumstances such as those described above, KFHPWA will make a good faith effort to arrange for Covered Services through available Network Facilities and personnel. KFHPWA shall have no other liability or obligation if Covered Services are delayed or unavailable due to unusual circumstances. PEBB_VA_2024 10

K. Utilization Management. “Case management” means a care management plan developed for an Enrollee whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review an Enrollee's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Enrollee except in the case of an intentional misrepresentation of a material fact by the patient, Enrollee, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading information provided on the enrollment application, or for nonpayment of premiums. III. Financial Responsibilities A. Premium. The Subscriber is liable for payment to the Group of their contribution toward the monthly premium, if any. B. Financial Responsibilities for Covered Services. The Subscriber is liable for payment of the following Cost Shares for Covered Services provided to the Subscriber and their Dependents. Payment of an amount billed must be received within 30 days of the billing date. Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that service. Cost Shares will not exceed the actual charge for that service. 1. Annual Deductible. Covered Services may be subject to an annual Deductible. Charges subject to the annual Deductible shall be borne by the Subscriber during each year until the annual Deductible is met. Covered Services must be received from a Network Provider at a Network Facility, unless the Enrollee has received Preauthorization or has received Emergency services. There is an individual annual Deductible amount for each Enrollee and a maximum annual Deductible amount for each Family Unit. Once the annual Deductible amount is reached for a Family Unit in a calendar year, the individual annual Deductibles are also deemed reached for each Enrollee during that same calendar year. 2. Plan Coinsurance. After the applicable annual Deductible is satisfied, Enrollees may be required to pay Plan Coinsurance for Covered Services. 3. Copayments. Enrollees shall be required to pay applicable Copayments at the time of service. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service or if other Cost Shares apply. 4. Out-of-pocket Limit. Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV. Total Out- of-pocket Expenses incurred during the same calendar year shall not exceed the Out-of-pocket Limit. C. Financial Responsibilities for Non-Covered Services. The cost of non-Covered Services and supplies is the responsibility of the Enrollee. The Subscriber is liable for payment of any fees charged for non-Covered Services provided to the Subscriber and their Dependents at the time of service. Payment of an amount billed must be received within 30 days of the billing date. PEBB_VA_2024 11

IV. Benefits Details Benefits are subject to all provisions of the EOC. Enrollees are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. Annual Deductible Annual Deductible without Wellness incentive: Enrollee pays $250 per Enrollee per calendar year or $750 per Family Unit per calendar year; or Annual Deductible with Wellness incentive: Subscriber Enrollee pays $125 per calendar year; dependent Enrollees pay $250 per calendar year or $625 per Family Unit per calendar year Prescription Drug Enrollee pays $100 per Enrollee per calendar year or $300 per Family Unit per calendar Deductible year Coinsurance Plan Coinsurance: Enrollee pays nothing Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Medical Out-of- Limited to a maximum of $3,000 per Enrollee or $6,000 per Family Unit per calendar year pocket Limit The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, Outpatient Pharmacy Drug Deductible, Outpatient Pharmacy Copayments, and Outpatient Pharmacy coinsurance, charges for non-Covered Services Prescription Drug Limited to a maximum of $2,000 per Enrollee or $8,000 per Family Unit per calendar year Out-of-pocket Limit The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: Prescription Drug Deductible, Copayments and coinsurance The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges which apply to the medical Out-of-Pocket limit, charges for non-Covered Services Pre-existing Condition No pre-existing condition waiting period Waiting Period PEBB_VA_2024 12

Acupuncture Acupuncture needle treatment, limited to 24 visits per After Deductible, Enrollee pays $30 primary care calendar year without Preauthorization. Additional visits are provider services Copayment covered with Preauthorization. No visit limit for treatment for Substance Use Disorder. Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Advanced Care at Home Advanced Care at Home is a personalized, patient-centered No charge, Enrollee pays nothing program that provides care for patients with certain clinical conditions in their homes, or at another appropriate care location such as a family member’s home or temporary residence. Advanced Care at Home services must be associated with an acute episode in which the member is treated for a brief but severe episode of illness, for conditions that are the result of disease such as, but not exclusive to, congestive heart failure, pneumonia, upper urinary tract infection or cellulitis. The treatment plan may include restorative care associated with the acute episode. The duration of an episode of care (which includes acute and restorative phases) is limited to a total of 30 days. To receive advanced care in the home: • The Enrollee must be referred into the advanced care program by the managing provider at an emergency room, urgent care, or inpatient setting, • Advanced Care at Home requires Preauthorization based on the Enrollee’s health status, treatment plan, and home setting or another appropriate care location within the Service Area, • The clinical condition must meet inpatient Medical Necessity criteria, • The Enrollee must consent to receiving advanced care described in the treatment plan, • The care location, such as the Enrollee’s residence, must be within 30 minutes ground travel time of an emergency department, and • The care location, such as the Enrollee’s residence, must, have cell service. Advanced Care at Home is provided through Medically Home, our Network provider, and they will provide the following services in the Enrollee’s home or appropriate care location: • Home visits by RNs, physical therapists, occupational therapists, speech therapists, respiratory PEBB_VA_2024 13

therapists, nutritionist, health aides, and other healthcare professionals in accordance with the Advanced Care at Home treatment plan and the provider’s scope of practice and licensure. • Communication devices to allow the Enrollee to contact the medical command center 24 hours a day, 7 days a week. This includes needed communication technology to support reliable connection for communication, and a personal emergency response system alert device to contact the medical command center if the Enrollee is unable to get to a phone. Additional services covered under this benefit include: • The following equipment necessary to ensure that you are monitored appropriately in your home: blood pressure cuff/monitor, pulse oximeter, scale, and thermometer. • Mobile imaging and tests such as X-rays, ultrasounds, and EKGs. • Safety items when Medically Necessary, such as shower stools, raised toilet seats, grabbers, long handled shoehorn, and sock aids. • Meals when Medically Necessary while you are receiving advanced care at home will be provided through our Network Provider, Medically Home. In addition, cost sharing is waived for the following covered services and items when the services and items are prescribed as part of your Advanced Care at Home treatment plan: • Durable Medical Equipment. • Medical Supplies. • Enrollee transportation to and from Network facilities when Enrollee transport is Medically Necessary will be arranged by Medically Home based on the most appropriate mode of transportation which could be ambulance, cabulance or otherwise. • Physician Assistant and Nurse Practitioner house calls. • Emergency Department visits associated with this benefit. The cost share is not waived and will apply to any services that are not part of your Advanced Care at Home treatment plan (for example, DME not specified in your Advanced Care at Home treatment plan). For outpatient prescription drug cost shares, see Drugs - Outpatient Prescription. Exclusions: Private Duty Nursing; housekeeping or meal services not part of your Advanced Care at Home treatment plan; any care provided by or for a family member; any other services rendered in the home which are not specified in your Advanced Care at Home treatment plan PEBB_VA_2024 14

Allergy Services Allergy testing. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Allergy serum and injections. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Ambulance Emergency ambulance service is covered only when: Enrollee pays 20% coinsurance • Transport to the nearest facility that can treat your condition • Any other type of transport would put your health or safety at risk. • The service is from a licensed ambulance. • The ambulance transports you to a location where you receive covered services. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency transportation to the nearest facility that can treat your condition, or ground Emergency transportation would put your health or safety at risk. Non-Emergency ground or air interfacility transfer to or from Enrollee pays 20% coinsurance a Network Facility where you receive covered services when Preauthorized by KFHPWA. Contact Member Services for Hospital-to-hospital ground transfers: No charge; Preauthorization. Enrollee pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in No charge; Enrollee pays nothing accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. See Preventive Services for additional information. Diagnostic laboratory and diagnostic services for cancer. See After Deductible, Enrollee pays nothing Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. PEBB_VA_2024 15

Circumcision Circumcision. (No charge if provided within 60 days of birth) Non-Emergency inpatient hospital services require Hospital - Inpatient: After Deductible, Enrollee Preauthorization. pays $250 Copayment per day up to $1,250 per admission Hospital - Outpatient: After Deductible, Enrollee pays $200 Copayment Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Clinical Trials Notwithstanding any other provision of this document, the Hospital - Inpatient: After Deductible, Enrollee Plan provides benefits for Routine Patient Costs of qualified pays $250 Copayment per day up to $1,250 per individuals in approved clinical trials, to the extent benefits admission for these costs are required by federal and state law. Hospital - Outpatient: After Deductible, Enrollee Routine patient costs include all items and services consistent pays $200 Copayment with the coverage provided in the plan (or coverage) that is typically covered for a qualified individual who is not Outpatient Services: After Deductible, Enrollee enrolled in a clinical trial. pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Clinical trials are a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition. “Life threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Clinical trials require Preauthorization. Exclusions: Routine patient costs do not include: (i) the investigational item, device, or service, itself; (ii) items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; or (iii) a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis Dental Services and Dental Anesthesia Dental services including accidental injury to natural teeth. Accidental injury: Hospital - Inpatient: After Deductible, Enrollee Dental Services (i.e., examination, evaluation and treatment) pays $250 Copayment per day up to $1,250 per necessitated by accidental injury to sound natural teeth. admission Evaluation and a written treatment plan must be completed Hospital - Outpatient: After Deductible, Enrollee within 30 days from the date of injury. Treatment must be pays $200 Copayment PEBB_VA_2024 16

completed within the treatment plan time frames. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Other dental services: Not covered, Enrollee pays 100% of all charges Dental services in preparation for treatment including but not Hospital - Inpatient: After Deductible, Enrollee limited to: chemotherapy, radiation therapy, and organ pays $250 Copayment per day up to $1,250 per transplants. Dental services (evaluation and treatment) in admission preparation for treatment require Preauthorization. Hospital - Outpatient: After Deductible, Enrollee Dental problems such as infections requiring emergency pays $200 Copayment treatment outside of standard business hours are covered as Emergency Services. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment General anesthesia services and related facility charges for Hospital - Inpatient: After Deductible, Enrollee dental procedures for Enrollees who are under 7 years of age pays $250 Copayment per day up to $1,250 per or are physically or developmentally disabled or have a admission Medical Condition where the Enrollee’s health would be put at risk if the dental procedure were performed in a dentist’s Hospital - Outpatient: After Deductible, Enrollee office. pays $200 Copayment General anesthesia services for dental procedures require Preauthorization. Exclusions: Injuries caused by biting or chewing; malocclusion as a result from an accidental injury; reconstructive surgery to the jaw in preparation for dental implants, dental implants, orthodontia; treatment not completed within the written treatment plan time frame, unless treatment is delayed due to a medical condition and the treatment plan is modified; any other dental service not specifically listed as covered Devices, Equipment and Supplies (for home use) Durable medical equipment: Equipment which can withstand Enrollee pays 20% coinsurance repeated use, is primarily and customarily used to serve a medical purpose, is useful only in the presence of an illness or Covered wigs or hairpieces limited to $100 lifetime injury and is used in the Enrollee’s home. maximum • Examples of covered durable medical equipment Annual Deductible does not apply to strip-based includes hospital beds, wheelchairs, walkers, crutches, blood glucose monitors, test strips, lancets or control canes, blood glucose monitors, external insulin pumps solutions. (including related supplies such as tubing, syringe cartridges, cannulae and inserters), oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks), and therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease. KFHPWA will determine if equipment is made available on a rental or purchase basis. • Orthopedic appliances: Items attached to an impaired body segment for the purpose of protecting the segment PEBB_VA_2024 17

or assisting in restoration or improvement of its function. • Ostomy supplies: Supplies for the removal of bodily secretions or waste through an artificial opening. • Post-mastectomy bras/forms, limited to 2 every 6 months. Replacements within this 6-month period are covered when Medically Necessary due to a change in the Enrollee’s condition. • Prosthetic devices: Items which replace all or part of an external body part, or function thereof. • Sales tax for devices, equipment and supplies. • Wigs or hairpieces for hair loss due to radiation or chemotherapy. When provided in lieu of hospitalization, benefits will be the greater of benefits available for devices, equipment and supplies, home health or hospitalization. See Advanced Care at Home for durable medical equipment provided in an Advanced Care at Home setting. See Hospice for durable medical equipment provided in a hospice setting. Devices, equipment and supplies including repair, adjustment or replacement of appliances and equipment require Preauthorization. Exclusions: Arch supports, including custom shoe modifications or inserts and their fittings not related to the treatment of diabetes; orthopedic shoes that are not attached to an appliance; wigs/hair prosthesis (except as noted above); take-home dressings and supplies following hospitalization; supplies, dressings, appliances, devices or services not specifically listed as covered above; same as or similar equipment already in the Enrollee’s possession; replacement or repair due to loss, theft, breakage from willful damage, neglect or wrongful use, or due to personal preference; structural modifications to a Enrollee’s home or personal vehicle Diabetic Education, Equipment and Pharmacy Supplies Diabetic education and training. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Diabetic equipment: Blood glucose monitors and external Enrollee pays 20% coinsurance insulin pumps (including related supplies such as tubing, syringe cartridges, cannulae and inserters), and therapeutic Annual Deductible does not apply to strip-based shoes, modifications and shoe inserts for severe diabetic foot blood glucose monitors, test strips, lancets or control disease. See Devices, Equipment and Supplies for additional solutions. information. Diabetic pharmacy supplies: Insulin, lancets, lancet devices, Value based medications which provide significant needles, insulin syringes, disposable insulin pens, pen value in treating chronic disease as determined by needles, glucagon emergency kits, prescriptive oral agents KFHPWA (Please contact Kaiser Permanente and blood glucose test strips for a supply of 30 days or less Member Services for a list of medications): Enrollee per item. Certain brand name insulin drugs will be covered at pays $5 Copayment the generic level. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): Enrollee pays $25 Copayment per 30-days up to a 90-day supply PEBB_VA_2024 18

Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $50 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance per 30-days up to a 90-day supply Preferred specialty brand name drugs (Tier 4): After Prescription Drug Deductible, Enrollee pays $150 Copayment up to a 30-day supply Non-Preferred specialty brand name drugs (Tier 5): After Prescription Drug Deductible, Enrollee pays 50% coinsurance up to $400 maximum up to a 30-day supply Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: An Enrollee will not pay more than $35, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. Diabetic retinal screening. No charge; Enrollee pays nothing Dialysis (Home and Outpatient) Dialysis in an outpatient or home setting is covered for Outpatient Services: After Deductible, Enrollee Enrollees with acute kidney failure or end-stage renal disease pays $30 primary care provider services Copayment (ESRD). or $50 specialty care provider services Copayment Dialysis requires Preauthorization. Injections administered by a Network Provider in a clinical Outpatient Services: After Deductible, Enrollee setting during dialysis. pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Self-administered injectables. See Drugs – Outpatient Value based medications which provide significant Prescription for additional pharmacy information. value in treating chronic disease as determined by KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $5 Copayment Preferred generic drugs (Tier 1): Enrollee pays $25 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $50 PEBB_VA_2024 19

Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance per 30-days up to a 90-day supply Preferred specialty brand name drugs (Tier 4): After Prescription Drug Deductible, Enrollee pays $150 Copayment up to a 30-day supply Non-Preferred specialty brand name drugs (Tier 5): After Prescription Drug Deductible, Enrollee pays 50% coinsurance up to $400 maximum up to a 30-day supply Drugs - Outpatient Prescription Prescription drugs, supplies and devices for a supply of 30 Value based medications which provide significant days or less including diabetic pharmacy supplies (insulin, value in treating chronic disease as determined by lancets, lancet devices, needles, insulin syringes, disposable KFHPWA (Please contact Kaiser Permanente insulin pens, pen needles and blood glucose test strips), Member Services for a list of medications): Enrollee mental health and wellness drugs, self-administered pays $5 Copayment injectables, medications for the treatment arising from sexual assault, and routine costs for prescription medications Preferred generic (Tier 1): Enrollee pays $25 provided in a clinical trial. “Routine costs” means items and Copayment per 30-days up to a 90-day supply services delivered to the Enrollee that are consistent with and typically covered by the plan or coverage for an Enrollee who Preferred brand name drugs (Tier 2): After is not enrolled in a clinical trial. All drugs, supplies and Prescription Drug Deductible, Enrollee pays $50 devices must be for Covered Services. Copayment per 30-days up to a 90-day supply All drugs, supplies and devices must be obtained at a Non-Preferred generic and brand name drugs KFHPWA-designated pharmacy except for drugs dispensed (Tier 3): After Prescription Drug Deductible, for Emergency services or for Emergency services obtained Enrollee pays 50% coinsurance per 30-days up to a outside of the KFHPWA Service Area, including out-of-the- 90-day supply country. Information regarding KFHPWA-designated pharmacies is reflected in the KFHPWA Provider Directory Preferred specialty brand name drugs (Tier 4): or can be obtained by contacting Kaiser Permanente Member After Prescription Drug Deductible, Enrollee pays Services. $150 Copayment up to a 30-day supply Prescription drug Cost Shares are payable at the time of Non-Preferred specialty brand name drugs (Tier delivery. Certain brand name insulin drugs are covered at the 5): After Prescription Drug Deductible, Enrollee generic drug Cost Share. pays 50% coinsurance up to $400 maximum up to a 30-day supply Enrollees may be eligible to receive an emergency fill for certain prescription drugs filled outside of KFHPWA’s Annual Deductible does not apply to strip-based business hours or when KFHPWA cannot reach the prescriber blood glucose monitors, test strips, lancets or control for consultation. For emergency fills, Enrollees pay the solutions. prescription drug Cost Share for each 7-day supply or less, or the minimum packaging size available at the time the Note: An Enrollee will not pay more than $35, not emergency fill is dispensed. A list of prescription drugs subject to the Deductible, for a 30-day supply of eligible for emergency fills is available on the pharmacy insulin to comply with state law requirements. Any website at www.kp.org/wa/formulary. Enrollees can request cost sharing paid will apply toward the annual PEBB_VA_2024 20

an emergency fill by calling 1-855-505-8107. Deductible. Certain drugs are subject to Preauthorization as shown in the Preferred drug list (formulary) available at www.kp.org/wa/formulary. For outpatient prescription drugs and/or items that are covered under the Drugs – Outpatient Prescription section and obtained at a pharmacy owned and operated by KFHPWA, an Enrollee may be able to use approved manufacturer coupons as payment for the Cost Sharing that an Enrollee owes, as allowed under KFHPWA’s coupon program. An Enrollee will owe any additional amount if the coupon does not cover the entire amount of the Cost Sharing for the Enrollee’s prescription. When an Enrollee uses an approved coupon for payment of their Cost Sharing, the coupon amount and any additional payment that you make will accumulate to their Deductible and Out-of-Pocket Limit. More information is available regarding the Kaiser Permanente coupon program rules and limitations at www.kp.org/rxcoupons. Injections administered by a Network Provider in a clinical After Deductible, Enrollee pays $30 primary care setting. provider services Copayment or $50 specialty care provider services Copayment Growth hormones. Value based medications which provide significant value in treating chronic disease as determined by KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $5 Copayment Preferred generic (Tier 1): Enrollee pays $25 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $50 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance per 30-days up to a 90-day supply Preferred specialty brand name drugs (Tier 4): After Prescription Drug Deductible, Enrollee pays $150 Copayment up to a 30-day supply Non-Preferred specialty brand name drugs (Tier 5): After Prescription Drug Deductible, Enrollee pays 50% coinsurance up to $400 maximum up to a 30-day supply Over-the-counter drugs not included under Preventive Care or Not covered; Enrollee pays 100% of all charges Reproductive Health. PEBB_VA_2024 21

Mail order drugs dispensed through the KFHPWA-designated Enrollee pays the prescription drug Cost Share for mail order service. each 90-day supply or less Value based medications which provide significant value in treating chronic disease as determined by KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $10 Copayment Preferred generic drugs (Tier 1): Enrollee pays $50 Copayment Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $100 Copayment Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance Annual Deductible does not apply to strip-based blood glucose monitors, test strips, lancets or control solutions. Note: An Enrollee will not pay more than $35, not subject to the Deductible, for a 30-day supply of insulin to comply with state law requirements. Any cost sharing paid will apply toward the annual Deductible. The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of physicians, pharmacists and a consumer representative who review the scientific evidence of these products and determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred drugs. The preferred drug list is available at www.kp.org/wa/formulary, or upon request from Member Services. An Enrollee, an Enrollee’s designee, or a prescribing physician may request a coverage exception to gain access to clinically appropriate drugs if the drug is not otherwise covered by contacting Member Services. Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits. KFHPWA will provide a determination and notification of the determination no later than 72 hours of the request after receipt of information sufficient to make a decision. The prescribing physician must submit an oral or written statement regarding the need for the non-Preferred drug, and a list of all of the preferred drugs which have been ineffective for the Enrollee. Expedited or Urgent Reviews: An Enrollee, an Enrollee’s designee, or a prescribing physician may request an expedited review for coverage for non-covered drugs when a delay caused by using the standard review process will seriously jeopardize the Enrollee’s life, health or ability to regain maximum function or will subject to the Enrollee to severe pain that cannot be managed adequately without the requested drug. KFHPWA or the IRO will provide a determination and notification of the determination no later than 24 hours from the receipt of the request after receipt of information sufficient to make a decision. Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can, PEBB_VA_2024 22

under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies printed in health care journals or other publications in which original manuscripts are published only after having been critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-house publications of pharmaceutical manufacturing companies. Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are dispensed if there is not a generic equivalent. In the event the Enrollee elects to purchase a brand-name drug instead of the generic equivalent (if available), the Enrollee is responsible for paying the difference in cost in addition to the brand-name prescription drug Cost Share, which does not apply to the Out-of-pocket Limit. Enrollee will never pay more than the actual cost of the prescription. Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when an Enrollee tries a certain medication before receiving coverage for a similar, but non-Preferred medication), limits on drug quantity or days supply and prevention of overutilization, underutilization, therapeutic duplication, drug-drug interactions, incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If an Enrollee has a new prescription for a chronic condition, the Enrollee may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized). Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at www.kp.org/wa/formulary or contact Member Services at 206-901-0107 or toll-free at 1-866-648-192. The Enrollee’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee Enrollees’ right to know what drugs are covered and the coverage limitations. Enrollees who would like more information about the drug coverage policies, or have a question or concern about their pharmacy benefit, may contact KFHPWA at 206-901-0107 or toll-free 1-866-648-192 or by accessing the KFHPWA website at www.kp.org/wa/formulary. Enrollees who would like to know more about their rights under the law, or think any services received while enrolled may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at toll-free 1-800-562-6900. Enrollees who have a concern about the pharmacists or pharmacies serving them may call the Washington State Department of Health at toll-free 1-800-525-0127. Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit. Enrollees who are also eligible for Medicare Part D can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D plan at a later date; however, the Enrollee could be subject to payment of higher Part D premiums if the Enrollee subsequently has a break in creditable coverage of 63 continuous days or longer before enrolling in a Part D plan. An Enrollee who discontinues coverage must meet eligibility requirements in order to re- enroll. PEBB_VA_2024 23

Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations, including most prescription vitamins, except as recommended by the U.S. Preventive Services Task Force (USPSTF); drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; replacement of lost, stolen, or damaged drugs or devices; administration of excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable Emergency Services Emergency services at a Network Facility or non-Network Network Facility: After Deductible, Enrollee pays Facility. See Section XII. for a definition of Emergency. $300 Copayment Emergency services include professional services, treatment Non-Network Facility: After Deductible, Enrollee and supplies, facility costs, outpatient charges for patient pays $300 Copayment observation, medical screening exams required to stabilize a patient and post stabilization treatment. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. If an Enrollee is admitted as an inpatient or to Advanced Care at Home directly from an emergency department, any Emergency services Copayment is waived. Coverage is subject to the applicable hospital services or Advanced Care at Home Cost Share. If an Enrollee is hospitalized in a non-Network Facility, KFHPWA reserves the right to require transfer of the Enrollee to a Network Facility upon consultation between a Network Provider and the attending physician. If the Enrollee refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Enrollee. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Gender Health Services Medically Necessary medical and surgical services for gender Hospital - Inpatient: After Deductible, Enrollee affirmation. Consultation and treatment require pays $250 Copayment per day up to $1,250 per Preauthorization. Certain procedures are subject to age limits, admission please see our clinical criteria https://wa- provider.kaiserpermanente.org/static/pdf/hosting/clinical/crite Hospital - Outpatient: After Deductible, Enrollee ria/pdf/gender_reassignment_surgery.pdf for details. pays $200 Copayment Outpatient Services: After Deductible, Enrollee PEBB_VA_2024 24

Prescription drugs are covered the same as for any other pays $30 primary care provider services Copayment condition (see Drugs – Outpatient Prescription for coverage) or $50 specialty care provider services Copayment Counseling services are covered the same as for any other condition (see Mental Health and Wellness for coverage). Non-Emergency inpatient hospital services require Preauthorization. Exclusions: Cosmetic services and surgery not related to gender affirming treatment (i.e., face lift or calf implants); complications of non-Covered Services Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered Hospital - Inpatient: After Deductible, Enrollee only when provided at KFHPWA-approved facilities. pays $250 Copayment per day up to $1,250 per admission Cochlear implants and surgically implanted Bone Anchored Hearing System (BAHS) when in accordance with KFHPWA Hospital - Outpatient: After Deductible, Enrollee clinical criteria. pays $200 Copayment Covered services for initial cochlear implants and surgically Outpatient Services: After Deductible, Enrollee implanted BAHS include diagnostic testing, pre-implant pays $30 primary care provider services Copayment testing, implant surgery, post-implant follow-up, speech or $50 specialty care provider services Copayment therapy, programming and associated supplies (such as transmitter cable, and batteries). Replacement devices and associated supplies – see Devices, Equipment and Supplies Section. Hearing aids, externally worn bone conduction hearing Enrollee pays nothing, limited to an Allowance of devices, and non-surgical Bone Anchored Hearing System $3,000 maximum per ear during any consecutive 36- (BAHS) for hearing loss. month period After Allowance: Not covered; Enrollee pays 100% of all charges Initial assessment, fitting, adjustments, auditory training and Outpatient Services: After Deductible, Enrollee ear molds as necessary to maintain optimal fit. pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Exclusions: Programs or treatments for hearing loss or hearing care including associated with externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services; replacement costs of hearing aids due to loss, breakage or theft, unless at the time of such replacement the Enrollee is eligible under the benefit Allowance; repairs; replacement parts; replacement batteries; maintenance costs Home Health Care Home health care when the following criteria are met: No charge; Enrollee pays nothing • Except for patients receiving palliative care services, the PEBB_VA_2024 25

Enrollee must be unable to leave home due to a health problem or illness. Unwillingness to travel and/or arrange for transportation does not constitute inability to leave the home. • The Enrollee requires intermittent skilled home health care, as described below. • KFHPWA’s medical director determines that such services are Medically Necessary and are most appropriately rendered in the Enrollee’s home. Covered Services for home health care may include the following when rendered pursuant to a KFHPWA-approved home health care plan of treatment: nursing care; restorative physical, occupational, respiratory and speech therapy; durable medical equipment; medical social worker and limited home health aide services. Home health services are covered on an intermittent basis in the Enrollee’s home. “Intermittent” means care that is to be rendered because of a medically predictable recurring need for skilled home health care. “Skilled home health care” means reasonable and necessary care for the treatment of an illness or injury which requires the skill of a nurse or therapist, based on the complexity of the service and the condition of the patient and which is performed directly by an appropriately licensed professional provider. Home health care requires Preauthorization. Exclusions: Private Duty Nursing; housekeeping or meal services; any care provided by or for a family member; any other services rendered in the home which do not meet the definition of skilled home health care above Hospice Hospice care when provided by a licensed hospice care No charge, Enrollee pays nothing program. A hospice care program is a coordinated program of home and inpatient care, available 24 hours a day. This program uses an interdisciplinary team of personnel to provide comfort and supportive services to an Enrollee and any family members who are caring for the Enrollee, who is experiencing a life-threatening disease with a limited prognosis. These services include acute, respite and home care to meet the physical, psychosocial and special needs of the Enrollee and their family during the final stages of illness. In order to qualify for hospice care, the Enrollee’s provider must certify that the Enrollee is terminally ill and is eligible for hospice services. Inpatient Hospice Services. For short-term care, inpatient hospice services are covered with Preauthorization. Respite care is covered to provide continuous care of the Enrollee and allow temporary relief to family members from PEBB_VA_2024 26

the duties of caring for the Enrollee for a maximum of 5 consecutive days per 3-month period of hospice care. Other covered hospice services, when billed by a licensed hospice program, may include the following: • Inpatient and outpatient services and supplies for injury and illness. • Semi-private room and board, except when a private room is determined to be necessary. • Durable medical equipment when billed by a licensed hospice care program. Hospice care requires Preauthorization. Exclusions: Private Duty Nursing, financial or legal counseling services; meal services; any services provided by family members Hospital - Inpatient and Outpatient The following inpatient medical and surgical services are Hospital - Inpatient: After Deductible, Enrollee covered: pays $250 Copayment per day up to $1,250 per • Room and board, including private room when admission prescribed, and general nursing services. • Hospital services (including use of operating room, Hospital - Outpatient: After Deductible, Enrollee anesthesia, oxygen, x-ray, laboratory and radiotherapy pays $200 Copayment services). • Drugs and medications administered during confinement. • Medical implants. • Withdrawal management services. Outpatient hospital includes ambulatory surgical centers. Alternative care arrangements may be covered as a cost- effective alternative in lieu of otherwise covered Medically Necessary hospitalization or other Medically Necessary institutional care with the consent of the Enrollee and recommendation from the attending physician or licensed health care provider. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Enrollee’s Medical Condition. Such care is covered to the same extent the replaced Hospital Care is covered. Alternative care arrangements require Preauthorization. Enrollees receiving the following nonscheduled services are required to notify KFHPWA by way of the Hospital notification line within 24 hours following any admission, or as soon thereafter as medically possible: acute withdrawal management services, Emergency psychiatric services, Emergency services, labor and delivery and inpatient admissions needed for treatment of Urgent Conditions that cannot reasonably be delayed until Preauthorization can be obtained. PEBB_VA_2024 27

Coverage for Emergency services in a non-Network Facility and subsequent transfer to a Network Facility is set forth in Emergency Services. Non-Emergency hospital services require Preauthorization. Exclusions: Take home drugs, dressings and supplies following hospitalization; internally implanted insulin pumps, artificial larynx and any other implantable device that have not been approved by KFHPWA’s medical director Infertility (including sterility) General counseling and one consultation visit to diagnose After Deductible, Enrollee pays $30 primary care infertility conditions. provider services Copayment or $50 specialty care provider services Copayment Specific diagnostic services, treatment and prescription drugs. Not covered; Enrollee pays 100% of all charges Exclusions: Diagnostic testing and medical treatment of sterility and infertility regardless of origin or cause; all charges and related services for donor materials; all forms of artificial intervention for any reason including artificial insemination and in-vitro fertilization; prognostic (predictive) genetic testing for the detection of congenital and heritable disorders; cryopreservation services; surrogacy; any services not specifically listed as covered Infusion Therapy Administration of Medically Necessary infusion therapy in an After Deductible, Enrollee pays $30 primary care outpatient setting. provider services Copayment or $50 specialty care provider services Copayment Preauthorization is required. Administration of Medically Necessary infusion therapy in No charge; Enrollee pays nothing the home setting. To receive benefits for the administration of select infusion medications in the home setting, the drugs must be obtained through KFHPWA’s preferred specialty pharmacy and administered by a provider we identify. For a list of these specialty drugs or for more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at www.kp.org/wa/formulary or contact Member Services. Associated infused medications includes, but is not limited to: After Deductible, Enrollee pays nothing • Antibiotics. • Hydration. • Chemotherapy. • Pain management. Preauthorization is required. PEBB_VA_2024 28

Laboratory and Radiology Nuclear medicine, radiology, ultrasound and laboratory After Deductible, Enrollee pays nothing services. Urine Drug Screening: Enrollee pays nothing. Services received as part of an emergency visit are covered as Limited to 2 tests per calendar year. Benefits are Emergency Services. applied in the order claims are received and processed. After allowance: After Deductible, Preventive laboratory and radiology services are covered in Enrollee pays nothing accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act Breast Exams: Enrollee pays nothing of 2010. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. CAT scan, MRI and PET which are subject to After Deductible, Enrollee pays $50 Copayment Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Manipulative Therapy Manipulative therapy of the spine and extremities when in After Deductible, Enrollee pays $30 primary care accordance with KFHPWA clinical criteria, limited to a total provider services Copayment or $50 specialty care of 24 visits per calendar year. Preauthorization is not provider services Copayment required. Rehabilitation services, such as massage or physical therapy, provided with manipulations is covered under the Massage Therapy or Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy section. Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved; care rendered primarily for the convenience of the Enrollee; care rendered on a non-acute, asymptomatic basis; charges for any other services that do not meet KFHPWA clinical criteria as Medically Necessary Massage Therapy Visits with licensed massage therapists to restore function After Deductible, Enrollee pays $50 specialty care immediately following illness, injury or surgery, limited to a provider services Copayment combined total of 24 visits per calendar year without Preauthorization. Outpatient services require a prescription or order from a physician that reflects a written plan of care to restore function. Exclusions: Recreational; life-enhancing, relaxation or services designed to relieve or soothe symptoms of a disease or disorder without effecting a cure (palliative therapy); massage therapists preventive services; any services not within the scope of the practitioner’s licensure PEBB_VA_2024 29

Maternity and Pregnancy Pregnancy care and services, including care for complications Hospital - Inpatient: After Deductible, Enrollee of pregnancy, in utero treatment for the fetus, prenatal testing pays $250 Copayment per day up to $1,250 per for the detection of congenital and heritable disorders when admission Medically Necessary and prenatal and postpartum care are covered for all Enrollees including eligible Dependents. Hospital - Outpatient: After Deductible, Enrollee Preventive services related to preconception, prenatal and pays $200 Copayment postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth Outpatient Services: After Deductible, Enrollee when Medically Necessary as determined by KFHPWA’s pays $30 primary care provider services Copayment medical director and in accordance with Board of Health or $50 specialty care provider services Copayment 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. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Enrollee’s provider, in consultation with the Enrollee, will determine the Enrollee’s length of inpatient stay following delivery. Donor human 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. Termination of pregnancy. Hospital - Inpatient: Enrollee pays nothing Non-Emergency inpatient hospital services require Hospital - Outpatient: Enrollee pays nothing Preauthorization. Outpatient Services: Enrollee pays nothing Exclusions: Birthing tubs; genetic testing of non-Enrollee; fetal ultrasound not considered Medically Necessary Mental Health and Wellness Mental health and wellness services provided at the most Hospital - Inpatient: After Deductible, Enrollee clinically appropriate and Medically Necessary level of pays $250 Copayment per day up to $1,250 per mental health care intervention as determined by KFHPWA’s admission medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these Hospital - Outpatient: After Deductible, Enrollee objectives. pays $200 Copayment Mental health and wellness services including medical Outpatient Services: After Deductible, Enrollee management and prescriptions are covered the same as for pays $30 primary care provider services Copayment any other condition. Group Visits: No charge; Enrollee pays nothing Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder or, has a PEBB_VA_2024 30

developmental disability for which there is evidence that ABA therapy is effective. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. If an Enrollee 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. Enrollees must notify 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 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 KFHPWA has approved specifically for the treatment of mental disorders. Non-Emergency inpatient hospital services, including Residential Treatment, require Preauthorization. Outpatient specialty services, including, partial hospitalization programs, rTMS, ECT, and Esketamine require Preauthorization. Routine outpatient therapy and psychiatry services with contracted network providers do not require Preauthorization. Exclusions: Specialty treatment programs such as “behavior modification programs” not considered Medically Necessary; relationship counseling or phase of life problems (Z code only diagnoses); wilderness therapy; aversion therapy Naturopathy Naturopathy. After Deductible, Enrollee pays $30 primary care PEBB_VA_2024 31

provider services Copayment Limited to 3 visits per medical diagnosis per calendar year without Preauthorization. Additional visits are covered with Preauthorization. Laboratory and radiology services are covered only when obtained through a Network Facility. Exclusions: Herbal supplements; nutritional supplements; any services not within the scope of the practitioner’s licensure Newborn Services Newborn services are covered the same as for any other Hospital - Inpatient: After Deductible, Enrollee condition. Any Cost Share for newborn services is separate pays $250 Copayment per day up to $1,250 per from that of the mother. admission Preventive services for newborns are covered under During the baby’s initial hospital stay while the birth Preventive Services. mother and baby are both confined, any applicable Deductible and Copayment for the newborn are When an Enrollee gives birth, the newborn is entitled to the waived benefits set forth in the EOC from birth through 3 weeks of age. After 3 weeks of age, no benefits are available unless the Hospital - Outpatient: After Deductible, Enrollee newborn child qualifies as a Dependent and is enrolled. See pays $200 Copayment Section VI. for enrollment information. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Nutritional Counseling Nutritional counseling. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care Services related to a healthy diet to prevent obesity are provider services Copayment covered as Preventive Services. See Preventive Services for additional information. Exclusions: Nutritional supplements; weight control self-help programs or memberships, such as Weight Watchers, Jenny Craig, or other such programs Nutritional Therapy Medical formula necessary for the treatment of After Deductible, Enrollee pays nothing phenylketonuria (PKU), specified inborn errors of metabolism, or other metabolic disorders. Enteral therapy is covered when Medical Necessity criteria After Deductible, Enrollee pays 20% coinsurance are met and when given through a PEG, J tube, or orally or for an eosinophilic gastrointestinal disorder. Necessary equipment and supplies for the administration of PEBB_VA_2024 32

enteral therapy are covered as Devices, Equipment and Supplies. Parenteral therapy (total parenteral nutrition). After Deductible, Enrollee pays nothing Necessary equipment and supplies for the administration of parenteral therapy are covered as Devices, Equipment and Supplies. Exclusions: Any other dietary formulas or medical foods; oral nutritional supplements that do not meet Medical Necessity criteria or re not related to the treatment of inborn errors of metabolism; special diets; prepared foods/meals Obesity Related Surgical Services Bariatric surgery is covered when KFHPWA criteria are met. Hospital - Inpatient: After Deductible, Enrollee pays $250 Copayment per day up to $1,250 per Bariatric surgery related services require Preauthorization. admission Services related to obesity screening and counseling are Hospital - Outpatient: After Deductible, Enrollee covered as Preventive Services. pays $200 Copayment Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Exclusions: Obesity treatment and treatment for morbid obesity for any reason including any medical services, drugs, supplies, regardless of co-morbidities, except as described above; specialty treatment programs such as weight control self-help programs or memberships, such as Weight Watchers, Jenny Craig or other such programs; medications and related physician visits for medication monitoring On the Job Injuries or Illnesses On the job injuries or illnesses. Office of Worker’s Compensation Programs (OWCP) or similar Federal or State agency pays through a third-party settlement: Not covered; Enrollee pays 100% of all charges After the third-party settlement maximum is paid: Hospital - Inpatient: After Deductible, Enrollee pays $250 Copayment per day up to $1,250 per admission Hospital - Outpatient: After Deductible, Enrollee pays $200 Copayment Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Exclusions: Confinement, treatment or service that results from an illness or injury arising out of or in the course of any employment for wage or profit including injuries, illnesses or conditions incurred as a result of self-employment; PEBB_VA_2024 33

Services needed because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or OWCP or a similar agency pays through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws Oncology Radiation therapy, chemotherapy, oral chemotherapy. Radiation Therapy and Chemotherapy: After Deductible, Enrollee pays $30 primary care See Infusion Therapy for infused medications. provider services Copayment or $50 specialty care provider services Copayment Oral Chemotherapy Drugs: Value based medications which provide significant value in treating chronic disease as determined by KFHPWA (Please contact Kaiser Permanente Member Services for a list of medications): Enrollee pays $5 Copayment Preferred generic drugs (Tier 1): Enrollee pays $25 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): After Prescription Drug Deductible, Enrollee pays $50 Copayment per 30-days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Prescription Drug Deductible, Enrollee pays 50% coinsurance per 30-days up to a 90-day supply Preferred specialty brand name drugs (Tier 4): After Prescription Drug Deductible, Enrollee pays $150 Copayment up to a 30-day supply Non-Preferred specialty brand name drugs (Tier 5): After Prescription Drug Deductible, Enrollee pays 50% coinsurance up to $400 maximum up to a 30-day supply Optical (vision) Routine eye examinations and refractions, limited to once Routine Exams: After Deductible, Enrollee pays every 12 months. $30 primary care provider services Copayment or $50 specialty care provider services Copayment Eye and contact lens examinations for eye pathology and to monitor Medical Conditions, as often as Medically Exams for Eye Pathology: After Deductible, Necessary. Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment PEBB_VA_2024 34

Enrollees age 19 and over: No charge; Enrollee pays nothing limited to an Eyeglass frames, lenses (any type), lens options such as Allowance of $150 every 24 months tinting, or prescription contact lenses, contact lens evaluations and examinations associated with their fitting. The benefit After Allowance, Enrollee pays 100% of all charges period begins on the date services are first obtained. The Allowance may be used toward the following in any Contact Lenses or Framed Lenses for Eye combination: Pathology: After Deductible, Enrollee pays nothing • Eyeglass frames • Eyeglass lenses (any type) including tinting and coating • Corrective industrial (safety) lenses • Sunglass lenses and frames when prescribed by an eye care provider for eye protection or light sensitivity • Corrective contact lenses in the absence of eye pathology, including associated fitting and evaluation examinations • Replacement frames, for any reason, including loss or breakage • Replacement contact lenses • Replacement eyeglass lenses Contact lenses or framed lenses for eye pathology when Medically Necessary. One contact lens per diseased eye in lieu of an intraocular lens is covered following cataract surgery provided the Enrollee has been continuously covered by KFHPWA since such surgery. In the event an Enrollee’s age or medical condition prevents the Enrollee from having an intraocular lens or contact lens, framed lenses are available. Replacement of lenses for eye pathology, including following cataract surgery, is covered only once within a 12-month period and only when needed due to a change in the Enrollee’s prescription. Replacement for loss or breakage is subject to the frames and lenses benefit. Frames and Lenses (in lieu of contract lenses): No charge; Enrollee pays nothing for 1 set of frames and Enrollee to age 19: lenses per calendar year Eyeglass frames, lenses (any type), lens options such as tinting, or prescription contact lenses, contact lens evaluations Contact lenses (in lieu of eyeglasses): Enrollee and examinations associated with their fitting. The benefit pays 50% coinsurance period begins on January 1 and continues through the end of the calendar year. The benefit may be used toward contact After benefit is exhausted: Not covered; Enrollee lenses (in lieu of eyeglasses) or 1 eyeglass frame and pair of pays 100% of all charges lenses. • Eyeglass frames Contact Lenses or Framed lenses for Eye • Eyeglass lenses (any type) including tinting and coating Pathology: After Deductible, Enrollee pays nothing • Corrective industrial (safety) lenses • Corrective contact lenses in the absence of eye pathology, including associated fitting and evaluation examinations Contact lenses or framed lenses for eye pathology when Medically Necessary. PEBB_VA_2024 35

One contact lens per diseased eye in lieu of an intraocular lens is covered following cataract surgery provided the Enrollee has been continuously covered by KFHPWA since such surgery. In the event an Enrollee’s age or medical condition prevents the Enrollee from having an intraocular lens or contact lens, framed lenses are available. Replacement of lenses for eye pathology, including following cataract surgery, is covered only once within a 12-month period and only when needed due to a change in the Enrollee’s prescription. Replacement for loss or breakage is subject to the frames and lenses benefit. Exclusions: Fees related to the lens fitting of non-network issued frames; orthoptic therapy (i.e., eye training); evaluations and surgical procedures to correct refractions not related to eye pathology and complications related to such procedures Oral Surgery Reduction of a fracture or dislocation of the jaw or facial Hospital - Inpatient: After Deductible, Enrollee bones; excision of tumors or non-dental cysts of the jaw, pays $250 Copayment per day up to $1,250 per cheeks, lips, tongue, gums, roof and floor of the mouth; and admission incision of salivary glands and ducts. Hospital - Outpatient: After Deductible, Enrollee KFHPWA’s medical director will determine whether the care pays $200 Copayment or treatment required is within the category of Oral Surgery or Dental Services. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment Oral surgery requires Preauthorization. or $50 specialty care provider services Copayment Exclusions: Care or repair of teeth or dental structures of any type; tooth extractions or impacted teeth; services related to malocclusion; services to correct the misalignment or malposition of teeth; any other services to the mouth, facial bones or teeth which are not medical in nature Outpatient Services Covered outpatient medical and surgical services in a After Deductible, Enrollee pays $30 primary care provider’s office, including chronic disease management and provider services Copayment or $50 specialty care treatment arising from sexual assault. See Preventive Services provider services Copayment for additional information related to chronic disease management. See Hospital - Inpatient and Outpatient for outpatient hospital medical and surgical services, including ambulatory surgical centers. Plastic and Reconstructive Surgery Plastic and reconstructive services: Hospital - Inpatient: After Deductible, Enrollee • Correction of a congenital disease or congenital anomaly. pays $250 Copayment per day up to $1,250 per admission PEBB_VA_2024 36

• Correction of a Medical Condition following an injury or resulting from surgery which has produced a major effect Hospital - Outpatient: After Deductible, Enrollee on the Enrollee’s appearance, when in the opinion of pays $200 Copayment KFHPWA’s medical director such services can reasonably be expected to correct the condition. Outpatient Services: After Deductible, Enrollee • Reconstructive surgery and associated procedures, pays $30 primary care provider services Copayment including internal breast prostheses, following a or $50 specialty care provider services Copayment mastectomy, regardless of when the mastectomy was performed. Enrollees are covered for all stages of reconstruction on the non-diseased breast to produce a symmetrical appearance. Complications of covered mastectomy services, including lymphedemas, are covered. Plastic and reconstructive surgery requires Preauthorization. Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery; cosmetic surgery; complications of non-Covered Services Podiatry Medically Necessary foot care. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care Routine foot care covered when such care is directly related provider services Copayment to the treatment of diabetes and, when approved by KFHPWA’s medical director, other clinical conditions that affect sensation and circulation to the feet. Exclusions: All other routine foot care Preventive Services Preventive services in accordance with the well care schedule No charge; Enrollee pays nothing established by KFHPWA may require Preauthorization. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. Screening and tests with A and B recommendations by the U.S. Preventive Services Task Force (USPSTF). Services, tests and screening contained in the U.S. Health Resources and Services Administration Bright Futures guidelines as set forth by the American Academy of Pediatricians. Services, tests, screening and supplies recommended in the U.S. Health Resources and Services Administration women’s preventive and wellness services guidelines. Immunizations recommended by the Centers for Disease Control’s Advisory Committee on Immunization Practices. PEBB_VA_2024 37

Flu vaccines are also covered when provided by a non- network provider. Preventive services include, but are not limited to, well adult and well child physical examinations; immunizations and vaccinations; preferred over-the-counter drugs as recommended by the USPSTF when obtained with a prescription; preventive services related to preconception, prenatal and postpartum care; routine mammography screening; routine prostate screening; colorectal cancer screening for Enrollees who are age 45 or older or who are under age 45 and at high risk; obesity screening/counseling; healthy diet; and physical activity counseling; depression screening in adults, including maternal depression, pre- exposure Prophylaxis (PrEP) for Enrollees at high risk for HIV infection, screening for physical, mental, sexual, and reproductive health care needs arising from a sexual assault. Preventive care for chronic disease management includes treatment plans with regular monitoring, coordination of care between multiple providers and settings, medication management, evidence-based care, quality of care measurement and results, and education and tools for patient self-management support. In the event preventive, wellness or chronic care management services are not available from a Network Provider, non-network providers may provide these services without Cost Share when Preauthorized. Services provided during a preventive services visit, including laboratory services, which are not in accordance with the KFHPWA well care schedule are subject to Cost Shares. Eye refractions are not included under preventive services. Exclusions: Those parts of an examination and associated reports and immunizations that are not deemed Medically Necessary by KFHPWA for early detection of disease; all other diagnostic services not otherwise stated above Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy Rehabilitation services to restore function following illness, Hospital - Inpatient: After Deductible, Enrollee injury or surgery, limited to the following restorative pays $250 Copayment per day up to $1,250 per therapies: occupational therapy, physical therapy, and speech admission therapy. Services are limited to those necessary to restore or improve functional abilities when physical, sensori-perceptual Outpatient Services: After Deductible, Enrollee and/or communication impairment exists due to injury, illness pays $50 Copayment or surgery. Group visits (occupational, physical, speech therapy Outpatient services require a prescription or order from a or learning services): After Deductible, Enrollee physician that reflects a written plan of care to restore pays one half of the office visit Copayment function and must be provided by a rehabilitation team that may include a physician, nurse, physical therapist, occupational therapist, or speech therapist. Preauthorization is PEBB_VA_2024 38

not required. Habilitative care, includes Medically Necessary services or devices designed to help an Enrollee keep, learn, or improve skills and functioning for daily living. Services may include occupational therapy, physical therapy, speech therapy when prescribed by a physician. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Limited to a combined total of 60 inpatient days and 60 outpatient visits per calendar year for all Rehabilitation, Habilitative care, and cardiac and pulmonary rehabilitation services. Neurodevelopmental therapy to restore or improve function including maintenance in cases where significant deterioration in the Enrollee’s condition would result without the services, limited to the following therapies: occupational therapy, physical therapy and speech therapy. There is no visit limit for Neurodevelopmental therapy. Services with mental health diagnoses are covered with no limit. Non-Emergency inpatient hospital services require Preauthorization. Cardiac rehabilitation is covered when clinical criteria are Outpatient Services: After Deductible, Enrollee met. pays $50 Copayment Preauthorization is required after initial limit. Limited to a combined total of 60 inpatient days and 60 outpatient visits per calendar year for all Rehabilitation, Habilitative care, cardiac and pulmonary rehabilitation services. Pulmonary rehabilitation is covered when clinical criteria are Outpatient Services: After Deductible, Enrollee met. pays $50 Copayment Preauthorization is required after initial visit. Limited to a combined total of 60 inpatient days and 60 outpatient visits per calendar year for all Rehabilitation, Habilitative care, cardiac and pulmonary rehabilitation services. Exclusions: Specialty treatment programs; inpatient Residential Treatment services; specialty rehabilitation programs including “behavior modification programs”; recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs PEBB_VA_2024 39

Reproductive Health Medically Necessary medical and surgical services for Hospital - Inpatient: No charge; Enrollee pays reproductive health, including consultations, examinations, nothing procedures and devices, including device insertion and removal. Hospital - Outpatient: No charge; Enrollee pays nothing See Maternity and Pregnancy for pregnancy care and termination of pregnancy services. Outpatient Services: No charge; Enrollee pays nothing Reproductive health is the care necessary to support the reproductive system and the ability to reproduce. Reproductive health includes contraception, cancer and disease screenings, termination of pregnancy, maternity, prenatal and postpartum care. All methods for Medically Necessary FDA-approved generic No charge; Enrollee pays nothing (including over-the-counter) contraceptive drugs, devices and products. Condoms are limited to 120 per 90-day supply, additional condoms available upon request. Contraceptive drugs may be allowed up to a 12-month supply and, when available, picked up in the provider’s office. Note: Over-the-counter contraceptives can be purchased at any KFHPWA-designated pharmacy. Designated pharmacies may submit the claim. If self-payment is made at a non- KFHWA-designated pharmacy, a reimbursement claim may be made by utilizing the Member Reimbursement Drug Claim Form which can be obtained in the “Forms & Publications” section on www.kp.org/wa or by calling Member Services. To request an exception for quantity limits on condoms, members may submit a request online at www.KP.org/wa/formulary or by contacting Member Services. Sexual Dysfunction Sexual dysfunction diagnosis and medical treatment services. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Penile prosthesis, when impotence is caused by a covered Enrollee pays 20% coinsurance medical condition, as a direct result of a covered surgery, or a result of an injury to the genitalia or spinal cord, and when other accepted treatment has been unsuccessful. Exclusions: Prescription drugs for treatment of sexual dysfunction; devices, equipment and supplies for the treatment of sexual dysfunction; penile prosthesis when not Medically Necessary; All other devices, equipment and supplies for the treatment of sexual dysfunction not specifically listed as covered PEBB_VA_2024 40

Skilled Nursing Facility Skilled nursing care in a skilled nursing facility when full- After Deductible, Enrollee pays $250 Copayment per time skilled nursing care is necessary in the opinion of the day up to $1,250 per admission attending physician, limited to a total of 150 days per calendar year. Care may include room and board; general nursing care; drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and short- term restorative occupational therapy, physical therapy and speech therapy. Skilled nursing care in a skilled nursing facility requires Preauthorization. Exclusions: Personal comfort items such as telephone and television; rest cures; domiciliary or Convalescent Care Sterilization FDA-approved female sterilization procedures, services and Hospital - Inpatient: No charge; Enrollee pays supplies. See Preventive Services for additional information. nothing Non-Emergency inpatient hospital services require Hospital - Outpatient: No charge; Enrollee pays Preauthorization. nothing Outpatient Services: No charge; Enrollee pays nothing Vasectomy. Hospital - Inpatient: No charge: Enrollee pays nothing Non-Emergency inpatient hospital services require Preauthorization. Hospital - Outpatient: No charge; Enrollee pays nothing Outpatient Services: No charge; Enrollee pays nothing Exclusions: Procedures and services to reverse a sterilization Substance Use Disorder Substance use disorder services including inpatient Hospital - Inpatient: After Deductible, Enrollee Residential Treatment; diagnostic evaluation and education; pays $250 Copayment per day up to $1,250 per organized individual and group counseling; and/or admission prescription drugs unless excluded under Sections IV. or V. Outpatient Services: After Deductible, Enrollee Substance use disorder means a substance-related or addictive pays $30 primary care provider services Copayment disorder listed in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). For the Group Visits: No charge; Enrollee pays nothing purposes of this section, the definition of Medically PEBB_VA_2024 41

Necessary shall be expanded to include those services necessary to treat a substance use disorder condition that is having a clinically significant impact on a Enrollee’s emotional, social, medical and/or occupational functioning. Substance use disorder services are limited to the services rendered by a physician (licensed under RCW 18.71 and RCW 18.57), a psychologist (licensed under RCW 18.83), a substance use disorder treatment program licensed for the service being provided by the Washington State Department of Social and Health Services (pursuant to RCW 70.96A), a master’s level therapist (licensed under RCW 18.225.090), an advance practice psychiatric nurse (licensed under RCW 18.79) or, in the case of non-Washington State providers, those providers meeting equivalent licensing and certification requirements established in the state where the provider’s practice is located. The severity of symptoms designates the appropriate level of care and should be determined through a thorough assessment completed by a licensed provider who recommends treatment based on medical necessity criteria. Court-ordered substance use disorder treatment shall be covered only if determined to be Medically Necessary. Preauthorization is required for outpatient, intensive outpatient, and partial hospitalization services. Preauthorization is not required for Residential Treatment and non-Emergency inpatient hospital services provided in-state. Enrollee is given two days of treatment and is then subject to medical necessity review for continued care. Enrollee or facility must notify KFHPWA within 24 hours of admission, or as soon as possible. Enrollee may request prior authorization for Residential Treatment and non-Emergency inpatient hospital services. Enrollee may contact Member Services to request Preauthorization. Withdrawal Management Services for Alcoholism and Emergency Services Network Facility: After Substance Use Disorder. Deductible, Enrollee pays $300 Copayment Withdrawal management services means the management of Emergency Services Non-Network Facility: After symptoms and complications of alcohol and/or substance Deductible, Enrollee pays $300 Copayment withdrawal. The severity of symptoms designates the appropriate level of care and should be determined through a Hospital - Inpatient: After Deductible, Enrollee thorough assessment completed by a licensed provider who pays $250 Copayment per day up to $1,250 per recommends treatment based on medical necessity criteria. admission Outpatient withdrawal management services means the symptoms resulting from abstinence are of mild/moderate severity and withdrawal from alcohol and/or other drugs can be managed with medication at an outpatient level of care by an appropriately licensed clinician. PEBB_VA_2024 42

Preauthorization is required for outpatient withdrawal management services. Coverage for inpatient withdrawal management services is provided without Preauthorization. If an Enrollee 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. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. Enrollee is given no less than two days of treatment, excluding weekends and holidays, in a behavioral health agency that provides inpatient or residential substance abuse treatment; and no less than three days in a behavioral health agency that provides withdrawal management services prior to conducting a medical necessity review for continued care. Enrollee or facility must notify KFHPWA within 24 hours of admission, or as soon as possible. Enrollees may request preauthorization for Residential Treatment and non- Emergency inpatient hospital services by contacting Member Services. KFHPWA reserves the right to require transfer of the Enrollee to a Network Facility/program upon consultation between a Network Provider and the attending physician. If the Enrollee refuses transfer to a Network Facility/program, all further costs incurred during the hospitalization are the responsibility of the Enrollee. Exclusions: Wilderness therapy or aversion therapy; facilities and treatment programs which are not certified by the Department of Social Health Services Telehealth Services Telemedicine Enrollee pays $10 Copayment Services provided by the use of real time interactive audio and video communications between the patient at the originating site and a Network provider at another location. Audio-only communication requires an Established Relationship. Store and forward technology means sending an Enrollee’s medical information from an originating site to the Provider at a distant site for later review. The Provider follows up with a medical diagnosis for the Enrollee and helps manage their care. Services must meet the following requirements: • Be a Covered Service under this EOC. • The originating site is qualified to provide the service. • If the service is provided through store and forward PEBB_VA_2024 43

technology, there must be an associated office visit between the Enrollee and the referring provider • Is medically necessary Telephone Services and Online (E-Visits) No charge; Enrollee pays nothing Scheduled telephone visits with a Network Provider are covered. Online (E-Visits): A Member logs into the secure Member site at www.kp.org/wa and completes a questionnaire. A KFHPWA medical provider reviews the questionnaire and provides a treatment plan for select conditions, including prescriptions. Online visits are not available to Enrollees during in-person visits at a KFHPWA facility or pharmacy. More information is available at https://wa.kaiserpermanente.org/html/public/services/e-visit. Exclusions: Fax and e-mail; telehealth services with non-contracted providers; telehealth services in states where prohibited by law; all other services not listed above Temporomandibular Joint (TMJ) Medical and surgical services and related hospital charges for After Deductible, Enrollee pays 50% coinsurance the treatment of temporomandibular joint (TMJ) disorders including: • Medically Necessary orthognathic procedures for the treatment of severe TMJ disorders which have failed non-surgical intervention. • Radiology services. • TMJ specialist services. • Fitting/adjustment of splints. Non-Emergency inpatient hospital services require Preauthorization. TMJ appliances. See Devices, Equipment and Supplies for Enrollee pays 50% coinsurance additional information. Exclusions: Treatment for cosmetic purposes; bite blocks; dental services including orthodontic therapy and braces for any condition; any orthognathic (jaw) surgery in the absence of a diagnosis of TMJ or severe obstructive sleep apnea; hospitalizations related to these exclusions Tobacco Cessation Individual/group counseling and educational materials. No charge; Enrollee pays nothing Approved pharmacy products. See Drugs – Outpatient No charge; Enrollee pays nothing PEBB_VA_2024 44

Prescription for additional pharmacy information. Transplants Transplant services, including heart, heart-lung, single lung, Hospital - Inpatient: After Deductible, Enrollee double lung, kidney, pancreas, cornea, intestinal/multi- pays $250 Copayment per day up to $1,250 per visceral, liver transplants, and bone marrow and stem cell admission support (obtained from allogeneic or autologous peripheral blood or marrow) with associated high dose chemotherapy. Hospital - Outpatient: After Deductible, Enrollee pays $200 Copayment Services are limited to the following: • Inpatient and outpatient medical expenses for evaluation Outpatient Services: After Deductible, Enrollee testing to determine recipient candidacy, donor matching pays $30 primary care provider services Copayment tests, hospital charges, procurement center fees, or $50 specialty care provider services Copayment professional fees, travel costs for a surgical team and excision fees. Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. • Follow-up services for specialty visits • Rehospitalization • Maintenance medications during an inpatient stay Organ Transplant Recipient: All services and supplies related to the organ transplant, including transportation to and from the KFHPWA Facilities (beyond the distance the Enrollee would normally be required to travel for most hospital services), are covered in accordance with the transplant benefit language, provided the Enrollee is accepted into the treating facility’s transplant program and continues to follow that program’s prescribed protocol. Organ Transplant Donor: The costs related to organ removal, as well as the cost of treating complications directly resulting from surgery, are covered, provided the organ recipient is an Enrollee under this Agreement, and provided the donor is not eligible for coverage under any other health care plan or government-funded program. Donor search costs for up to 15 searches only for allogeneic bone marrow transplants. Transplant services must be provided through locally and nationally contracted or approved transplant centers. All transplant services require Preauthorization. Contact Member Services for Preauthorization. Exclusions: Donor costs to the extent that they are reimbursable by the organ donor’s insurance; living expenses except as covered under Section II.K. Utilization Management; transportation expenses except as covered above; costs for searches for non-allogeneic bone marrow donors PEBB_VA_2024 45

Urgent Care Inside the KFHPWA Service Area, urgent care is covered at a Network Emergency Department: After Kaiser Permanente medical center, Kaiser Permanente urgent Deductible, Enrollee pays $300 Copayment care center or Network Provider’s office. Network Urgent Care Center: After Deductible, Outside the KFHPWA Service Area, urgent care is covered at Enrollee pays $30 primary care provider services any medical facility. Copayment or $50 specialty care provider services Copayment See Section XII. for a definition of Urgent Condition. Network Provider’s Office: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Non-Network Provider: After Deductible, Enrollee pays $300 Copayment V. General Exclusions In addition to exclusions listed throughout the EOC, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the EOC, except as required by federal or state law. 2. Services Related to Non-Covered Services: When a service is not covered, all services related to the non- covered service (except for the specific exceptions described below) are also excluded from coverage. Enrollees who have received a non-covered service, such as bariatric surgery, and develop an acute medical complication (such as band slippage, leak or infection) as a result, shall have coverage for Medically Necessary intervention to stabilize the acute medical complication. Coverage does not include complications that occur during or immediately following a non-covered service. Additional surgeries or other medical services in addition to Medically Necessary intervention to resolve acute medical complications resulting from non-covered services shall not be covered. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Enrollee had no health care coverage or for which the Enrollee is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Enrollee as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Enrollee if the Enrollee receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. PEBB_VA_2024 46

7. Services provided by government agencies, except as required by federal or state law. 8. Services covered by the national health plan of any other country. 9. Experimental or investigational services. KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a particular service is experimental or investigational. a. A service is considered experimental or investigational for a Enrollee’s condition if any of the following statements apply to it at the time the service is or will be provided to the Enrollee: 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted. 2) The service is the subject of a current new drug or new device application on file with the FDA. 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a qualifying Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial. 4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity or efficacy as among its objectives. 5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy of services. 6) The service is provided pursuant to informed consent documents that describe the service as experimental or investigational, or in other terms that indicate that the service is being evaluated for its safety, toxicity or efficacy. 7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific literature, is that (1) the use of such service should be substantially confined to research settings, or (2) further research is necessary to determine the safety, toxicity or efficacy of the service. b. The following sources of information will be exclusively relied upon to determine whether a service is experimental or investigational: 1) The Enrollee’s medical records. 2) The written protocol(s) or other document(s) pursuant to which the service has been or will be provided. 3) Any consent document(s) the Enrollee or Enrollee’s representative has executed or will be asked to execute, to receive the service. 4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews research at the institution where the service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service, as applied to the Enrollee’s illness or injury. 6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions. Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to KFHPWA's medical director at P.O. Box 34593, Seattle, WA 98124-1593. 10. Hypnotherapy and all services related to hypnotherapy. 11. Directed umbilical cord blood donations. 12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing for non- Enrollees. 13. Autopsy and associated expenses. PEBB_VA_2024 47

14. Over-the-counter items such as hearing aids unless specifically listed as covered in Section IV. 15. Academic/career counseling, counseling for overeating, work/school ordered assessments, relationship counseling, custodial care 16. Court-ordered or forensic treatment, including reports and summaries, not considered Medically Necessary. VI. Eligibility, Enrollment and Termination In these sections, “health plan” is used to refer to a plan offering medical or dental, or both, developed by the Public Employees Benefits Board (PEBB) and provided by a contracted vendor or self-insured plans administered by the Health Care Authority (HCA). A. Eligibility. 1. Eligible Employees. The employee’s state agency will inform the employee in writing whether or not they are eligible for PEBB benefits upon employment and whenever their eligibility status changes. The written notice will include information about the employee’s right to appeal eligibility and enrollment decisions. An employee of an employer group (such as a county, city, port, water district, etc.) that contracts with HCA for PEBB benefits should contact their payroll or benefits office for eligibility criteria. Employees have the right to appeal eligibility and enrollment decisions. Information about appeals can be found under “Appeal Rights”. 2. Continuation coverage eligibility The PEBB Program determines whether subscribers are eligible for continuation coverage (COBRA or Unpaid Leave) upon receipt of their election to enroll in PEBB Continuation Coverage (COBRA or Unpaid Leave). If the subscriber requests to enroll in and is not eligible for continuation coverage, the PEBB Program will notify them of their right to appeal. Information about appeals can be found under “Appeal Rights”. 3. Retired employee of a former employer group eligibility The PEBB Program determines whether a retired employee or a retired school employee of a former employer group is eligible to self-pay coverage upon receipt of their election to enroll. If the retired employee or the retired school employee requests to enroll and is not eligible, the PEBB Program will notify them of their right to appeal. Information about appeals can be found under “Appeal rights.” 4. Eligible Dependents. The following are eligible as dependents: 1. Legal spouse. 2. State-registered domestic partner and substantially equivalent legal unions from jurisdictions as defined in Washington State statute. Individuals in a state-registered domestic partnership are treated the same as a legal spouse except when in conflict with federal law. 3. Children. Children are eligible through the last day of the month in which their 26th birthday occurred regardless of marital status, student status, or eligibility for coverage under another plan. It also includes children age 26 or older with a disability as described below in “Children of any age with a developmental or physical disability.”. Children are defined as the subscriber’s: a. Children based on establishment of a parent-child relationship, as described in Washington State statutes, except when parental rights have been terminated; b. Children of the subscriber’s spouse, based on the spouse’s establishment of a parent-child relationship, except when parental rights have been terminated. The stepchild’s relationship to the PEBB_VA_2024 48

subscriber (and eligibility as a dependent) ends on the same date the marriage with the spouse ends through divorce, annulment, dissolution, termination, or death; c. Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child; d. Children of the subscriber’s state-registered domestic partner, based on the state-registered domestic partner’s establishment of a parent-child relationship, except when parental rights have been terminated. The child’s relationship to the subscriber (and eligibility as a dependent) ends on the same date the subscriber’s legal relationship with the state-registered domestic partner ends through divorce, annulment, dissolution, termination, or death; e. Children specified in a court order or divorce decree for whom the subscriber has a legal obligation to provide support or health care coverage; f. Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber’s spouse, or the subscriber’s state-registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child’s official residence with the custodian or guardian. Extended dependent child does not include foster children unless the subscriber, the subscriber’s spouse, or the subscriber’s state-registered domestic partner has assumed a legal obligation for total or partial support in anticipation of adoption; and g. Children of any age with a developmental or physical disability that renders them incapable of self-sustaining employment and chiefly dependent upon the subscriber for support and maintenance provided such condition occurs before the age of 26. The following requirements apply to a dependent child with a disability: The subscriber must provide proof of the disability and dependency within 60 days of the • child’s attainment of age 26; The subscriber must notify the PEBB Program in writing, when the child is no longer eligible • under this subsection; A child with a developmental or physical disability who becomes self-supporting is not eligible • as of the last day of the month in which they become capable of self-support; A child with a developmental or physical disability age 26 and older who becomes capable of • self-support does not regain eligibility under this subsection if they later become incapable of self-support; and The PEBB Program with input from the medical plan will periodically verify the eligibility of a • dependent child with a disability beginning at age 26, but no more frequently than annually after the two-year period following the child’s 26th birthday. Verification will require renewed proof of disability and dependence from the subscriber. B. Enrollment for subscribers and dependents. 1. For all Subscribers and Dependents • To enroll at any time other than during the initial enrollment period, see “Making changes.” • Any Dependents enrolled in medical coverage will be enrolled in the same medical plan as the Subscriber. Exceptions apply for non-Medicare enrollees when a subscriber selects a Medicare Supplement, Medicare Advantage, or Medicare Advantage Prescription Drug plan. 2. Employee enrollment An employee must reside or work in the Service Area. An employee’s dependent must also reside in the plan’s service area, except for temporary residency outside the Service Area for purposes of attending school, court-ordered coverage for Dependents or other unique family arrangements, when approved in advance by KFHPWA. KFHPWA has the right to verify eligibility. An employee must use Benefits 24/7, the online enrollment system (once available), or submit a PEBB Employee Enrollment/Change or PEBB Employee Enrollment/Change (for Medical Only Groups) form and PEBB_VA_2024 49

any supporting documents to their employing agency when they become newly eligible or regain eligibility for PEBB benefits. The online enrollment must be completed or the form must be received no later than 31 days after the date the employee becomes eligible or regains eligibility. If the employee does not enroll online or return the form by the deadline, the employee will be enrolled in Uniform Medical Plan Classic, and a tobacco use premium surcharge will be incurred. Consequently, dependents cannot be enrolled until the PEBB Program’s next annual open enrollment or when a qualifying event occurs that creates a special open enrollment for enrolling a dependent. 3. Waiving medical enrollment An eligible employee may waive enrollment in PEBB medical if they are enrolled in other employer-based group medical, a TRICARE plan, or Medicare. They may not waive enrollment in PEBB medical if they are enrolled in PEBB retiree insurance coverage. When a retiree becomes eligible for the employer contribution toward PEBB benefits, PEBB retiree insurance coverage will be automatically deferred. If an employee waives enrollment in PEBB medical, the employee cannot enroll eligible dependents. For information on when an eligible employee may waive medical plan enrollment after their initial enrollment period, or to enroll after having waived, see “Making changes.” 4. Continuation coverage enrollment A subscriber enrolling in PEBB Continuation Coverage (COBRA or Unpaid Leave) may enroll by using Benefits 24/7, the online enrollment system (once available), or by submitting the applicable PEBB Continuation Coverage Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or the PEBB Program must receive the election form no later than 60 days from the date the enrollee’s PEBB health plan coverage ended or from the postmark date on the PEBB Continuation Coverage Election Notice sent by the PEBB Program, whichever is later. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described above. For more information, see “Options for continuing PEBB medical coverage” and the PEBB Continuation Coverage Election Notice. 5. Retired employee of a former employer group enrollment A retired employee or a retired school employee of a former employer group may enroll and self-pay premiums using Benefits 24/7, the online enrollment system (once available), or by submitting the PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or the PEBB Program must receive the required form no later than 60 days after the employer group ended their participation. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described above. Note: Enrollment in the Kaiser Permanente WA Medicare Advantage (MA) plan may not be retroactive. If a subscriber is eligible for and elects this plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in another Kaiser Permanente WA plan during the gap month(s) prior to when the Kaiser Permanente WA MA plan begins. 6. Dependent enrollment To enroll an eligible dependent, the employee must include the dependent’s information online using Benefits 24/7 (once available) or on the applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility. The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program or the employing agency is unable to verify their eligibility within the PEBB Program enrollment timelines. PEBB_VA_2024 50

7. National Medical Support Notice (NMSN). When a National Medical Support Notice (NMSN) requires a subscriber to provide health plan coverage for a dependent child the following provisions apply: The subscriber may enroll their dependent child and request changes to their health plan coverage as described under “Changes to health plan coverage or enrollment are allows as directed by the NMSN,” below. • An employee must use Benefits 24/7 (once available) or submit the required form(s) to their employing agency. • Any other subscriber must use Benefits 24/7 (once available) or submit the required form(s) to the PEBB Program. If the subscriber fails to request enrollment or health plan coverage changes as directed by the NMSN, the employing agency or the PEBB Program may make enrollment or health plan coverage changes according to “Changes to health plan coverage or enrollment are allowed as directed by the NMSN,” below, upon request of: • The child’s other parent; or • Child support enforcement program. Changes to health plan coverage or enrollment are allowed as directed by the NMSN: a. The dependent will be enrolled under the subscriber’s health plan coverage as directed by the NMSN; b. An employee who has waived PEBB medical will be enrolled in medical as directed by the NMSN, in order to enroll the dependent; c. The subscriber’s selected health plan will be changed if directed by the NMSN; d. If the dependent is already enrolled under another PEBB subscriber, the dependent will be removed from the other health plan coverage and enrolled as directed by the NMSN; e. If the dependent is enrolled in both PEBB medical and School Employee Benefits Board (SEBB) medical as a dependent and there is NMSN in place, enrollment will be in accordance with the NMSN; or f. If the subscriber is eligible for and elects Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage or other continuation coverage, the NMSN will be enforced and the dependent must be covered in accordance with the NMSN. Changes to health plan coverage or enrollment as described in subsection (a) through (c) will begin the first day of the month following receipt of the NMSN. If the NMSN is received on the first day of the month, the change to health plan coverage or enrollment begins on that day. A dependent will be removed from the subscriber’s health plan coverage as described in (d) the last day of the month the NMSN is received. If that day is the first of the month, the change in enrollment will be made the last day of the previous month. When a NMSN requires a spouse, former spouse, or other individual to provide health plan coverage for a dependent who is already enrolled in the subscriber’s PEBB coverage, and that health plan coverage is in fact provided, the dependent may be removed from the subscriber’s PEBB health plan coverage prospectively. 8. Dual enrollment A subscriber and their dependents may each be enrolled in only one PEBB medical plan. An employee or their dependent who is eligible to enroll in both the PEBB Program and the School Employees Benefits Board (SEBB) Program is limited to a single enrollment in either the PEBB or SEBB Program. PEBB_VA_2024 51

For example: • A child who is an eligible dependent under two parents enrolled in PEBB Program benefits may be enrolled as a dependent under both parents but is limited to a single enrollment in PEBB medical. • A child who is an eligible dependent of an employee in the PEBB Program and a school employee in the SEBB Program may only be enrolled as a dependent under one parent in either the PEBB or SEBB Program. C. Medicare Eligibility and Enrollment. 1. Employee and dependent If an employee or their dependent becomes eligible for Medicare, they should contact the Social Security Administration to ask about the advantages of immediate or deferred Medicare enrollment. An employee or their dependent are deemed eligible for Medicare when they have the option to receive Part A Medicare benefits. If an employee or their dependent chooses to enroll in Medicare Part A, Medicare regulations and guidelines will determine whether Medicare is the primary or secondary payer. An employee or their dependent who is enrolled in Medicare may remain enrolled in PEBB medical coverage. However, an employee may choose to waive their PEBB medical plan or remove their dependent from their PEBB medical plan and choose Medicare as their primary insurer. If an employee does so, neither the employee nor their dependent can enroll in PEBB medical except during the annual open enrollment or a special open enrollment. In most situations, an employee and their dependent can elect to defer Medicare Part B enrollment without a penalty while enrolled in PEBB medical coverage. When the employee terminates employment, the employee and the dependent can enroll in Medicare Part B during a Special Enrollment Period. If Medicare eligibility is due to disability, the employee or their dependent must contact the Social Security Administration about deferring enrollment in Medicare Part B. Upon retirement, Medicare will become the primary insurance payer, and the PEBB medical plan will become secondary. See “PEBB retiree insurance coverage.” 2. Continuation coverage subscriber, a retired employee of a former employer group, or their dependent If a continuation coverage subscriber, a retired employee of a former employer group, or their dependent becomes eligible for Medicare, federal regulations allow enrollment in Medicare three months before they turn age 65. If they do not enroll within three months before the month they turn age 65, enrollment in Medicare may be delayed. If enrollment in Medicare does not occur when the subscriber or their dependent is first eligible, a late enrollment penalty may apply. D. When Medical Coverage Begins. 1. Employees and dependents For a newly eligible employee and their eligible dependents, medical coverage begins the first day of the month following the date the employee becomes eligible. If the employee becomes eligible on the first working day of the month, then coverage begins on that date. If the eligible employee is a faculty member hired on a quarter-to-quarter or semester-to-semester basis, medical coverage begins the first day of the month following the beginning of the second consecutive quarter or semester. If the first day of the second consecutive quarter or semester is the first working day of the month, medical coverage begins on that day. For an employee regaining eligibility, including following a period of leave or after being between periods of leave described in PEBB Program rules, and their eligible dependents, medical coverage begins the first day of the month the employee is in pay status eight or mor hours. If the employee is a faculty member regaining eligibility no later than the 12th month after the month in which they lost eligibility for the employer contribution toward PEBB benefits, medical coverage begins the first day of the month in which the quarter or semester begins. PEBB_VA_2024 52

Note: When an employee who is called to active duty in the uniformed services under the Uniformed Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer contribution toward PEBB benefits, they regain eligibility for the employer contribution toward PEBB benefits the day they return from active duty. Medical coverage begins the first day of the month in which the employee returns from active duty. 2. Continuation coverage subscriber and dependents For a continuation coverage subscriber and their eligible dependents enrolling when newly eligible due to a qualifying event, medical coverage begins the first day of the month following the day they lost eligibility for PEBB medical plan coverage. 3. Retired employees of a former eployer group and dependents For a retired employee of a former employer group and their eligible dependents enrolling when newly eligible, medical coverage begins the first day of the month following the day they lost eligibility for PEBB retiree insurance coverage. 4. All Subscribers and dependents For a subscriber or their eligible dependents enrolling during the PEBB Program’s annual open enrollment, medical coverage begins January 1 of the following year. For a subscriber or their eligible dependents enrolling during a special open enrollment, medical coverage begins the first day of the month following the later of the event date or the date the online enrollment election using Benefits 24/7 (once available) or the required form is received. If that day is the first of the month, medical coverage begins on that day, except for a Medicare Advantage or Medicare Advantage Prescription Drug plan, which will begin the first day of the month following the date the enrollment election is received online or the required form is received by the PEBB Program. If the special open enrollment is due to the , or when the subscriber has birth or adoption of a child assumed a legal obligation for total or partial support in anticipation of adoption of a child, medical coverage will begin as follows: • For an employee, medical coverage will begin the first day of the month in which the event occurs. • For a newly born child, medical coverage will begin the date of birth. • For a newly adopted child, medical coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier. • For a spouse or state registered domestic partner of a subscriber, medical coverage will begin the first day of the month in which the event occurs. If the special open enrollment is due to the enrollment of an extended dependent, or a dependent child with a disability, medical coverage will begin on the first day of the month following the event date or eligibility certification, whichever is later. E. Making changes 1. Removing a dependent who is no longer eligible A subscriber must provide notice to remove a dependent who is no longer eligible due to divorce, annulment, dissolution, or a qualifying event of a dependent ceasing to be eligible as a dependent child as described under “Dependent eligibility.” The notice must be received within 60 days of the last day of the month the dependent no longer meets the eligibility criteria. • An employee must provide notice online using Benefits 24/7 (once available) or by submitting a written request to their employing agency. • Any other subscriber must provide notice online using Benefits 24/7 (once available) or by submitting a written request to the PEBB Program. Consequences for not submitting notice within the required 60 days may include, but are not limited to: PEBB_VA_2024 53

• The dependent may lose eligibility to continue PEBB medical coverage under one of the continuation coverage options described in “Options for continuing PEBB medical coverage.” • The subscriber may be billed for claims paid by the medical plan for services that were rendered after the dependent lost eligibility. • The subscriber may not be able to recover subscriber-paid insurance premiums for the dependent that lost eligibility. • The subscriber may be responsible for premiums paid by the state for the dependent’s medical plan coverage after the dependent lost eligibility. 2. Voluntary termination for continuation coverage subscribers or retired employees of a former employer group A continuation coverage subscriber or a retired employee of a former employer group may voluntarily terminate enrollment in a medical plan at any time by submitting a request online using Benefits 24/7 (once available) or in writing to the PEBB Program. Enrollment in the medical plan will be terminated the last day of the month in which the request was received online or by the PEBB Program, or on the last day of the month specified in the termination request, whichever is later. If the request is received on the first day of the month, medical plan enrollment will be terminated on the last day of the previous month. Exception: When a subscriber or their dependent is enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, then medical plan enrollment will terminate on the last day of the month when the PEBB Medicare Advantage Plan Disenrollment form (form D) is received. 3. Making changes during annual open enrollment and special open enrollment A subscriber may make certain changes to their enrollment during the annual open enrollment and if a specific life event creates a special open enrollment period. 4. Annual Open Enrollment changes. An employee may make the following changes to their enrollment during the PEBB Program’s annual open enrollment period: • Change their medical plan • Waive their medical plan enrollment • Enroll after waiving medical plan enrollment • Enroll or remove eligible dependents An employee must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. The change must be completed online or the forms received, no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. Any other subscriber may make the following changes to their enrollment during the PEBB Program’s annual open enrollment period: • Enroll in or terminate enrollment in a medical plan • Enroll or remove eligible dependents • Change their medical plan A continuation coverage subscriber must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (COBRA) Election/Change, or PEBB Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. The change must be completed online, or the forms PEBB_VA_2024 54

received no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. A retired employee of a former employer group must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, or the forms received, no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. 5. Special Open Enrollment changes. A subscriber may change their enrollment outside of the annual open enrollment if a qualifying event creates a special open enrollment period. However, the change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, their dependent, or both. A special open enrollment may allow a subscriber to make the following changes: Enroll in or change their medical plan • Waive their medical plan enrollment • Enroll after waiving medical plan enrollment • Enroll or remove eligible dependents • To request a special open enrollment: • An employee must make the change online using Benefits 24/7 (once available) or submit the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. • A continuation coverage subscriber must make the change online using Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (COBRA) Election/Change, or PEBB Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. • A retired employee of a former employer group must make the change online using Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, or the forms must be received, no later than 60 days after the event that creates the special open enrollment. In addition, the PEBB Program or the employing agency will require the subscriber to provide proof of a dependent’s eligibility, evidence of the event that created the special open enrollment, or both. Exceptions: • If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage, the subscriber should notify their employing agency or the PEBB Program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A continuation coverage subscriber or a retired employee of a former employer group: • Has six months from the date of their or their dependent’s enrollment in Medicare Part B to change their enrollment to a PEBB Medicare Supplement Plan. The change must be made online using Benefits 24/7 (once available), or the PEBB Program must receive the required form(s) no later than six months after the enrollment in Medicare Part B for either the subscriber or their dependent. PEBB_VA_2024 55

• When they or their dependent is enrolled in a Medicare Advantage (MA) or Medicare Advantage- Prescription Drug (MAPD) plan, they may disenroll during a special enrollment period as allowed under federal regulations. The new medical plan coverage will begin the first day of the month following the date the PEBB Medicare Advantage Plan Disenrollment form (form D) is received. • Has seven months to enroll in an MA or MAPD plan that begins three months before they or their dependent first enrolled in both Medicare Part A and Part B and ends three months after the month of Medicare eligibility. They may also enroll themselves or their dependent in an MA or MAPD plan before their last day of the Medicare Part B initial enrollment period. The change must be made online using Benefits 24/7 (once available), or the forms must be received by the PEBB Program, no later than the last day of the month prior to the month the, or their dependent enrolls in the MA or MAPD plan. 6. Special open enrollment events that allow for a change in health plans A subscriber may not change their health plan during a special open enrollment if their state-registered domestic partner or state-registered domestic partner’s child is not a tax dependent. Any of the following events may create a special open enrollment: • Subscriber gains a new dependent due to: o Marriage or registering a state-registered domestic partnership. o Birth, adoption, or assuming a legal obligation for total or partial support in anticipation of adoption. o A child becoming eligible as an extended dependent through legal custody or legal guardianship. • Subscriber or their dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA). • Subscriber has a change in employment status that affects their eligibility for the employer contribution toward their employer-based group health plan. • Subscriber’s dependent has a change in their own employment status that affects their eligibility or their dependent’s eligibility for the employer contribution under their employer-based group health plan. “Employer contribution” means contributions made by the dependent’s current or former employer toward health coverage as described in the Treasury Regulation. • Subscriber or their dependent has a change in residence that affects health plan availability. If the subscriber has a change in residence and their current medical plan is no longer available, the subscriber must select a new medical plan as described in PEBB Program rules. If the subscriber does not elect a new medical plan as required, they will be enrolled in a PEBB medical plan designated by the director of HCA or their designee. • A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is not an eligible dependent). • Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the subscriber or their dependent loses eligibility for coverage under Medicaid or CHIP. • Subscriber or their dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP. • Subscriber or their dependent enrolls in coverage under Medicare, or the subscriber or their dependent loses eligibility for coverage under Medicare or enrolls in or terminates enrollment in a Medicare Advantage-Prescription Drug or a Part D plan. If the subscriber’s current medical plan becomes PEBB_VA_2024 56

unavailable due to the subscriber or their dependents enrollment in Medicare, the subscriber must select a new medical plan. • Subscriber or their dependent’s current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). • Subscriber or their dependent experiences a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the subscriber or their dependent. The subscriber may not change their health plan election because the subscriber or dependent’s physician stops participation with the subscriber’s health plan unless the PEBB Program determines that a continuity of care issue exists. The PEBB Program will consider but not limit its consideration to the following: o Active cancer treatment, such as chemotherapy or radiation therapy o Treatment following a recent organ transplant o A scheduled surgery o Recent major surgery still within the postoperative period o Treatment for a high-risk pregnancy • The PEBB Program determines that there has been a substantial decrease in the providers available under a PEBB medical plan. Note: The plan cannot guarantee that any physician, hospital, or other provider will be available or remain under contract with the plan. An enrollee may not change medical plans simply because their provider or health care facility discontinues participation with this medical plan until the PEBB Program’s next annual open enrollment or when another qualifying event creates a special open enrollment for changing health plans, unless the PEBB Program determines that a continuity of care issue exists or there has been a substantial decrease in the providers available under the plan. 7. Special open enrollment events that allow adding or removing a dependent Any of the following events may create a special open enrollment: • Subscriber gains a new dependent due to: o Marriage or registering a state-registered domestic partnership. o Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption. o A child becoming eligible as an extended dependent through legal custody or legal guardianship. • Subscriber or their dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA). • Subscriber has a change in employment status that affects their eligibility for the employer contribution toward their employer-based group health plan. • Subscriber’s dependent has a change in their own employment status that affects their eligibility or their dependent’s eligibility for the employer contribution under their employer-based group health plan. “Employer contribution” means contributions made by the dependent’s current or former employer toward health coverage as described in the Treasury Regulation. • Subscriber or their dependent has a change in enrollment under an employer-based group health plan during its annual open enrollment that does not align with the PEBB Program’s annual open enrollment. • Subscriber’s dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and that change in residence resulted in the dependent losing their health insurance. PEBB_VA_2024 57

• A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is not an eligible dependent). • Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the subscriber or their dependent loses eligibility for coverage under Medicaid or CHIP. • Subscriber or their dependent becomes eligible for a state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP. • Subscriber’s dependent enrolls in Medicare or loses eligibility for Medicare. 8. Special open enrollment events that allow waiving medical enrollment and enrolling after waiving An employee may waive PEBB medical during a special open enrollment if they are enrolled in other employer-based group medical, a TRICARE plan, or Medicare. An employee may not waive enrollment in PEBB medical if they are enrolled in PEBB retiree insurance coverage. Any of the following events may create a special open enrollment: • Employee gains a new dependent due to: o Marriage or registering a state-registered domestic partnership. o Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption. o A child becoming eligible as an extended dependent through legal custody or legal guardianship. • Employee or their dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the HIPAA. • Employee has a change in employment status that affects their eligibility for the employer contribution toward their employer-based group medical. • Employee’s dependent has a change in their own employment status that affects their eligibility or their dependent’s eligibility for the employer contribution under their employer-based group medical. “Employer contribution” means contributions made by the dependent’s current or former employer toward health coverage as described in the Treasury Regulation. • Employee or their dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the PEBB Program’s annual open enrollment. • Employee’s dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and the change in residence resulted in the dependent losing their health insurance. • A court order requires the employee or any other individual to provide a health plan for an eligible dependent of the employee (a former spouse or former state-registered domestic partner is not an eligible dependent). • Employee or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the employee or their dependent loses eligibility for coverage under Medicaid or CHIP. Note: An employee may only return from having waived PEBB medical for the events described in this paragraph. An employee may not waive their PEBB medical for the events described in this paragraph. • Employee or their dependent becomes eligible for a state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP. PEBB_VA_2024 58

• Employee or their dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan. • Employee becomes eligible and enrolls in Medicare or loses eligibility for Medicare. F. When medical coverage ends 1. Termination dates Medical coverage ends on the following dates: • On the last day of the month when any enrollee ceases to be eligible. • On the date a medical plan terminates due to a change in contracted service area or when the group policy ends. If that should occur, the subscriber will have the opportunity to enroll in another PEBB medical plan. • For an employee and their dependents, on the last day of the month the employment relationship is terminated. The employment relationship is considered terminated: o On the date specified in an employee’s letter of resignation. o On the date specified in any contract or hire letter. o On the effective date of an employer-initiated termination notice. Note: If the employing agency deducted the employee’s premium for PEBB insurance coverage after the employee was no longer eligible for the employer contribution, medical coverage ends the last day of the month for which employee premiums were deducted. • For a continuation coverage subscriber or a retired employee of a former employer group who submits a request to terminate medical coverage, enrollment in medical coverage will be terminated the last day of the month in which the request was received online using Benefits 24/7 (once available) or by the PEBB Program, or on the last day of the month specified in the termination request, whichever is later. If the request is received on the first day of the month, medical coverage will be terminated on the last day of the previous month. Exception: When a subscriber or their dependent is enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, the medical plan enrollment will terminate on the last day of the month when the PEBB Medicare Advantage Plan Disenrollment form (form D) is received. A subscriber will be responsible for payment of any services received after the date medical coverage ends as described above. 2. Final premium payments Premium payments and applicable premium surcharges are not prorated during any month, for any reason, even if an enrollee dies or asks to terminate their medical plan before the end of the month. If the monthly premium or applicable premium surcharges remain unpaid for 30 days, the account will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance and applicable premium surcharges. If the subscriber’s premium balance or applicable premium surcharges remain unpaid for 60 days from the original due date, the subscriber’s medical coverage (including enrolled dependents) will be terminated retroactive to the last day of the month for which the monthly premiums and any applicable premium surcharges were paid. For a subscriber enrolled in a Medicare Advantage or a Medicare Advantage-Prescription Drug plan, a notice will be sent notifying them that they are delinquent on their monthly premium and that the enrollment will be terminated prospectively to the end of the month after the notice is sent. PEBB_VA_2024 59

3. If an enrollee is hospitalized An enrollee who is receiving covered services in a hospital on the date medical coverage ends will continue to be eligible for covered services while an inpatient for the condition which the enrollee was hospitalized, until one of the following events occur: • According to this plan’s clinical criteria, it is no longer medically necessary for the enrollee to be an inpatient at the facility. • The remaining benefits available for the hospitalization are exhausted, regardless of whether a new calendar year begins. • The enrollee becomes covered under another agreement with a group health plan that provides benefits for the hospitalization. • The enrollee becomes enrolled under an agreement with another carrier that provides benefits for the hospitalization. This provision will not apply if the enrollee is covered under another agreement that provides benefits for the hospitalization at the time medical coverage ends, except as set forth in this section, or if the enrollee is eligible for PEBB Continuation Coverage as described in “Options for continuing PEBB medical coverage.” 4. Options for continuing PEBB medical coverage When medical coverage ends, the subscriber and their dependents covered by this medical plan may be eligible to continue PEBB medical coverage during temporary or permanent loss of eligibility. There are three options the subscriber and their dependents may qualify for when coverage ends. • PEBB Continuation Coverage (COBRA) • PEBB Continuation Coverage (Unpaid Leave) • PEBB retiree insurance coverage A subscriber also has the right to convert to individual medical insurance coverage with the plan when continuation of group medical insurance coverage is no longer possible. (a) PEBB Continuation Coverage The PEBB Program administers the following continuation coverage options to temporarily extend group insurance coverage when the enrollee’s PEBB medical plan coverage ends due to a qualifying event: • PEBB Continuation Coverage (COBRA) includes eligibility and administrative requirements under federal COBRA laws and regulations. Some enrollees who are not qualified beneficiaries under federal COBRA, may also qualify for PEBB Continuation Coverage (COBRA). • PEBB Continuation Coverage (Unpaid Leave) is an option created by the PEBB Program with wider eligibility criteria and qualifying event types than COBRA. An enrollee who qualifies for both types of PEBB Continuation Coverage (COBRA and Unpaid Leave) may enroll in only one of these options. See “Continuation coverage enrollment” and the PEBB Continuation Coverage Election Notice. Premium payments for PEBB Continuation Coverage If a subscriber enrolls in continuation coverage, the subscriber is responsible for timely payment of premiums and applicable premium surcharges. (b) PEBB retiree insurance coverage The following are eligible to continue enrollment or defer enrollment in PEBB retiree insurance coverage if they meet procedural and substantive eligibility requirements: PEBB_VA_2024 60

• Retiring employee • Retiring school employee • Eligible elected or full-time appointed official of the legislative or executive branch of state government leaving public office • Dependent becoming eligible as a survivor • Retiree or survivor enrolled in PEBB retiree insurance coverage For details, see the PEBB Retiree Enrollment Guide. 5. Family and Medical Leave Act of 1993 An employee on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to receive the employer contribution toward PEBB benefits in accordance with the federal FMLA. The employing agency determines if the employee is eligible for leave and the duration of the leave under FMLA. The employee must continue to pay their monthly premium contribution and applicable premium surcharges during this period to maintain eligibility. If an employee exhausts the period of leave approved under FMLA, they may continue PEBB insurance coverage by self-paying the monthly premium and applicable premium surcharges set by HCA, with no contribution from the employing agency. See “Options for continuing PEBB medical coverage.” 6. Paid Family and Medical Leave Act An employee on approved leave under the Washington State Paid Family and Medical Leave (PFML) Program may continue to receive the employer contribution toward PEBB benefits. The Employment Security Department determines if the employee is eligible for leave under PFML. The employee must continue to pay their monthly premium contribution and applicable premium surcharges during this period to maintain eligibility. If an employee exhausts the period of leave approved under PFML, they may continue PEBB insurance coverage by self-paying the monthly premium and applicable premium surcharges set by HCA, with no contribution from the employing agency. See “Options for continuing PEBB medical coverage.” 7. Conversion of coverage An enrollee (including a spouse or dependent of a subscriber terminated for cause) has the right to switch from PEBB group medical to an individual conversion plan offered by this plan when they are no longer eligible to continue the PEBB group medical plan and are not eligible for Medicare or covered under another group insurance coverage that provides benefits for hospital or medical care. An enrollee must apply for conversion coverage and pay the first month’s premium no later than 31 days after their group medical plan ends or within 31 days from the date the notice of termination of coverage is received, whichever is later. Evidence of insurability (proof of good health) is not required to obtain the conversion coverage. Rates, coverage, and eligibility requirements of this conversion plan differ from those of the enrollee’s current group medical plan. To receive detailed information on conversion options under this medical plan, call us at (206) 630-0107 in the Seattle area, or toll-free in Washington, 1-866-648-1928. G. General provisions for eligibility and enrollment 1. Payment of premiums during a labor dispute Any employee or dependent whose monthly premiums are paid in full or in part by the employing agency may pay premiums directly to HCA if the employee’s compensation is suspended or terminated directly or indirectly because of a strike, lockout, or any other labor dispute, for a period not to exceed six months. PEBB_VA_2024 61

When the employee’s compensation is suspended or terminated, HCA will notify the employee immediately, by mail at the last address of record, that the employee may pay premiums as they become due. If coverage is no longer available to the employee under this certificate of coverage, then the employee may be eligible to purchase an individual medical plan from this plan consistent with premium rates filed with the Washington State Office of the Insurance Commissioner. 2. Termination for just cause The purpose of this provision is to allow for a fair and consistent method to process the plan-designated provider’s request to terminate coverage from this plan for just cause. An eligible dependent may have coverage terminated by HCA for the following reasons: • Failure to comply with the PEBB Program’s procedural requirements, including failure to provide information or documentation requested by the due date in written requests from the PEBB Program • Knowingly providing false information • Failure to pay the monthly premium and applicable premium surcharges when due • Misconduct. Examples of such termination include, but are not limited to the following: o Fraud, intentional misrepresentation or withholding of information the subscriber knew or should have known was material or necessary to accurately determine eligibility or the correct premium o Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan, or other HCA-contracted vendor providing PEBB insurance coverage on behalf of HCA, its employees, or other persons The PEBB Program will enroll an employee and their eligible dependents in another PEBB medical plan upon termination from this plan. H. Appeal rights Any current or former employee of a state agency or their dependent may appeal a decision made by the state agency regarding PEBB eligibility, enrollment, or premium surcharges to the state agency. Any current or former employee of an employer group, such as a county, city, port, water district, etc., that contracts with HCA for PEBB benefits, or their dependent may appeal a decision made by an employer group regarding PEBB eligibility, enrollment, or premium surcharges to the employer group. Any enrollee may appeal a decision made by the PEBB Program regarding PEBB eligibility, enrollment, premium payments, or premium surcharges to the PEBB Appeals Unit. Any enrollee may appeal a decision regarding the administration of a PEBB medical plan by following the appeal provisions of the plan, except when regarding eligibility, enrollment, and premium payment decisions. Learn more at hca.wa.gov/pebb-appeals. I. Relationship to law and regulations Any provision of this certificate of coverage that is in conflict with any governing law or regulation of Washington State is hereby amended to comply with the minimum requirements of such law or regulation. VII. Grievances Grievance means a written or verbal complaint submitted by or on behalf of a covered person regarding service delivery issues other than denial of payment for medical services or non-provision of medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier. The grievance process is outlined as follows: PEBB_VA_2024 62

Step 1: It is recommended that the Enrollee contact the person involved or the manager of the medical center/department where they are having a problem, explain their concerns and what they would like to have done to resolve the problem. The Enrollee should be specific and make their position clear. Most concerns can be resolved in this way. Step 2: If the Enrollee is still not satisfied, they should write to Member Services at P.O. Box 34590, Seattle, WA 98124-1590, or call at 206-630-0107 or toll-free 1-866-648-192. Most concerns are handled by phone within a few days. In some cases, the Enrollee will be asked to write down they concerns and state what they think would be a fair resolution to the problem. An appropriate representative will investigate the Enrollee’s concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant plan policies and the Enrollee Rights and Responsibilities statement. This process can take up to 30 days to resolve after receipt of the Enrollee’s written or verbal statement. If the Enrollee is dissatisfied with the resolution of the complaint, they may contact Member Services. Assistance is available to Enrollees who are limited-English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to request review or participate in the review process. VIII. Appeals Enrollees are entitled to appeal through the appeals process if/when coverage for an item or service is denied due to an adverse determination made by the KFHPWA medical director. The appeals process is available for an Enrollee to seek reconsideration of an adverse benefit determination (action). Adverse benefit determination (action) means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Enrollee’s eligibility to participate in a plan, and including, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not Medically Necessary or appropriate. KFHPWA will comply with any new requirements as necessary under federal laws and regulations. Assistance is available to Enrollees who are limited-English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to request review or participate in the review process. The most current information about your appeals process is available by contacting KFHPWA’s Member Appeal Department at the address or telephone number below. 1. Initial Appeal If the Enrollee or the Enrollee’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why they disagree with the decision. The appeal must be submitted within 180 days of receipt of the denial notice. KFHPWA will notify the Enrollee of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, P.O. Box 34593, Seattle, WA 98124-1593, toll-free 1-866-458-5479. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Enrollee of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Enrollee’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Enrollee in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Enrollee’s life, health or ability to regain maximum function or subject the Enrollee to severe pain that cannot be managed adequately without the requested care or treatment. The Enrollee can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 1-866-458-5479. The nature of the patient’s condition will be PEBB_VA_2024 63

evaluated by a physician and if the request is not accepted as urgent, the Enrollee will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Enrollee’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Enrollee may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Enrollee is in an ongoing course of treatment. If the Enrollee requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Enrollee may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, P.O. Box 40256, Olympia, WA 98504-0256 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at http://www.insurance.wa.gov/your-insurance/health-insurance/appeal/. 2. Next Level of Appeal If the Enrollee is not satisfied with the decision regarding medical necessity, medical appropriateness, health care setting, level of care, or if the requested service is not efficacious or otherwise unjustified under evidence- based medical criteria, or if KFHPWA fails to adhere to the requirements of the appeals process, the Enrollee may request a second level review by an external independent review organization not legally affiliated with or controlled by KFHPWA. KFHPWA will notify the Enrollee of the name of the external independent review organization and its contact information. The external independent review organization will accept additional written information for up to five business days after it receives the assignment for the appeal. The external independent review will be conducted at no cost to the Enrollee. Once a decision is made through an independent review organization, the decision is final and cannot be appealed through KFHPWA. If the Enrollee requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Enrollee may be responsible for the cost of coverage received during the review period. A request for a review by an independent review organization must be made within 180 days after the date of the initial appeal decision notice. IX. Claims Claims for benefits may be made before or after services are obtained. KFHPWA recommends that the provider requests Preauthorization. In most instances, contracted providers submit claims directly to KFHPWA. If your provider does not submit a claim to make a claim for benefits, a Enrollee must contact Member Services, or submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider about care or coverage, or submitting a prescription to a pharmacy, will not be considered a claim for benefits. If an Enrollee receives a bill for services the Enrollee believes are covered, the Enrollee must, within 90 days of the date of service, or as soon thereafter as reasonably possible, either (1) contact Member Services to make a claim or (2) pay the bill and submit a claim for reimbursement of Covered Services to KFHPWA, or (3) for out-of-country claims (Emergency care only) – submit the claim and any associated medical records, including the type of service, charges, and proof of travel to KFHPWA, P.O. Box 30766, Salt Lake City, UT 84130-0766. In no event, except in the absence of legal capacity, shall a claim be accepted later than 1 year from the date of service. PEBB_VA_2024 64

KFHPWA will generally process claims for benefits within the following timeframes after KFHPWA receives the claims: • Immediate request situations – within 1 business day. • Concurrent urgent requests – within 24 hours. • Urgent care review requests – within 48 hours. • Non-urgent preservice review requests – within 5 calendar days. • Post-service review requests – within 30 calendar days. Timeframes for pre-service and post-service claims can be extended by KFHPWA for up to an additional 15 days. Enrollee will be notified in writing of such extension prior to the expiration of the initial timeframe. X. Coordination of Benefits The coordination of benefits (COB) provision applies when a Enrollee has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Enrollee is covered by more than one health benefit plan, and the Enrollee does not know which is the primary plan, the Enrollee or the Enrollee’s provider should contact any one of the health plans to verify which plan is primary. The health plan the Enrollee contacts is responsible for working with the other plan to determine which is primary and will let the Enrollee know within 30 calendar days. All health plans have timely claim filing requirements. If the Enrollee or the Enrollee’s provider fails to submit the Enrollee’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If the Enrollee experiences delays in the processing of the claim by the primary health plan, the Enrollee or the Enrollee’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. If the Enrollee is covered by more than one health benefit plan, the Enrollee or the Enrollee’s provider should file all the Enrollee’s claims with each plan at the same time. If Medicare is the Enrollee’s primary plan, Medicare may submit the Enrollee’s claims to the Enrollee’s secondary carrier. Definitions. A. A plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for Enrollees of a Group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts. However, if COB rules do not apply to all contracts, or to all benefits in the same contract, the contract or benefit to which COB does not apply is treated as a separate plan. 1. Plan includes: group, individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance organizations (HMO), closed panel plans or other forms of group coverage; medical care components of long-term care contracts, such as skilled nursing care; and Medicare or any other federal governmental plan, as permitted by law. 2. Plan does not include: hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non- medical components of long-term care policies; automobile insurance policies required by statute to PEBB_VA_2024 65

provide medical benefits; Medicare supplement policies; Medicaid coverage; or coverage under other federal governmental plans; unless permitted by law. Each contract for coverage under Subsection 1. or 2. is a separate plan. If a plan has two parts and COB rules apply only to one of the two, each of the parts is treated as a separate plan. B. This plan means, in a COB provision, the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans. Any other part of the contract providing health care benefits is separate from this plan. A contract may apply one COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits. C. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the Enrollee has health care coverage under more than one plan. When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan’s benefits. When this plan is secondary, it determines its benefits after those of another plan and must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal 100% of the total allowable expense for that claim. This means that when this plan is secondary, it must pay the amount which, when combined with what the primary plan paid, totals 100% of the allowable expense. In addition, if this plan is secondary, it must calculate its savings (its amount paid subtracted from the amount it would have paid had it been the primary plan) and record these savings as a benefit reserve for the covered Enrollee. This reserve must be used by the secondary plan to pay any allowable expenses not otherwise paid, that are incurred by the covered person during the claim determination period. D. Allowable Expense. Allowable expense is a health care expense, coinsurance or copayments and without reduction for any applicable deductible, that is covered at least in part by any plan covering the person. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering the Enrollee is not an allowable expense. The following are examples of expenses that are not allowable expenses: 1. The difference between the cost of a semi-private hospital room and a private hospital room is not an allowable expense, unless one of the plans provides coverage for private hospital room expenses. 2. If an Enrollee is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement method or other similar reimbursement method, any amount in excess of the highest reimbursement amount for a specific benefit is not an allowable expense. 3. If an Enrollee is covered by two or more plans that provide benefits or services on the basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense. 4. An expense or a portion of an expense that is not covered by any of the plans covering the person is not an allowable expense. E. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services through a panel of providers who are primarily employed by the plan, and that excludes coverage for services provided by other providers, except in cases of Emergency or referral by a panel member. F. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. PEBB_VA_2024 66

Order of Benefit Determination Rules. When an Enrollee is covered by two or more plans, the rules for determining the order of benefit payments are as follows: A. The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan. B. (1) Except as provided below (subsection 2), a plan that does not contain a coordination of benefits provision that is consistent with this chapter is always primary unless the provisions of both plans state that the complying plan is primary. (2) Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage is excess to any other parts of the plan provided by the contract holder. Examples include major medical coverages that are superimposed over hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits. C. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan. D. Each plan determines its order of benefits using the first of the following rules that apply: 1. Non-Dependent or Dependent. The plan that covers the Enrollee other than as a Dependent, for example as an employee, member, policyholder, Subscriber or retiree is the primary plan and the plan that covers the Enrollee as a Dependent is the secondary plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the Enrollee as a Dependent, and primary to the plan covering the Enrollee as other than a Dependent (e.g., a retired employee), then the order of benefits between the two plans is reversed so that the plan covering the Enrollee as an employee, member, policyholder, Subscriber or retiree is the secondary plan and the other plan is the primary plan. 2. Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, when a dependent child is covered by more than one plan the order of benefits is determined as follows: a) For a dependent child whose parents are married or are living together, whether or not they have ever been married: • The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or • If both parents have the same birthday, the plan that has covered the parent the longest is the primary plan. b) For a dependent child whose parents are divorced or separated or not living together, whether or not they have ever been married: i. If a court decree states that one of the parents is responsible for the dependent child’s health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. This rule applies to claim determination periods commencing after the plan is given notice of the court decree; ii. If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses, the plan of the parent assuming financial responsibility is primary; iii. If a court decree states that both parents are responsible for the dependent child’s health care expenses or health care coverage, the provisions of a) above determine the order of benefits; iv. If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of Subsection a) above determine the order of benefits; or v. If there is no court decree allocating responsibility for the dependent child’s health care expenses or health care coverage, the order of benefits for the child are as follows: • The plan covering the custodial parent, first; PEBB_VA_2024 67

• The plan covering the spouse of the custodial parent, second; • The plan covering the non-custodial parent, third; and then • The plan covering the spouse of the non-custodial parent, last. c) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the provisions of Subsection a) or b) above determine the order of benefits as if those individuals were the parents of the child. 3. Active employee or retired or laid-off employee. The plan that covers a Enrollee as an active employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan covering that same Enrollee as a retired or laid off employee is the secondary plan. The same would hold true if a Enrollee is a Dependent of an active employee and that same Enrollee is a Dependent of a retired or laid-off employee. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section D.1. can determine the order of benefits. 4. COBRA or State Continuation Coverage. If an Enrollee whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another plan, the plan covering the Enrollee as an employee, member, Subscriber or retiree or covering the Enrollee as a Dependent of an employee, member, Subscriber or retiree is the primary plan and the COBRA or state or other federal continuation coverage is the secondary plan. If the other plan does not have this rule, and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under section D.1. can determine the order of benefits. 5. Longer or shorter length of coverage. The plan that covered the Enrollee as an employee, member, Subscriber or retiree longer is the primary plan and the plan that covered the Enrollee the shorter period of time is the secondary plan. 6. If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it would have paid had it been the primary plan. Effect on the Benefits of this Plan. When this plan is secondary, it must make payment in an amount so that, when combined with the amount paid by the primary plan, the total benefits paid or provided by all plans for the claim equal one hundred percent of the total allowable expense for that claim. However, in no event shall the secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. In no event should the Enrollee be responsible for a deductible amount greater than the highest of the two deductibles. Right to Receive and Release Needed Information. Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this plan and other plans. KFHPWA may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the Enrollee claiming benefits. KFHPWA need not tell, or get the consent of, any Enrollee to do this. Each Enrollee claiming benefits under this plan must give KFHPWA any facts it needs to apply those rules and determine benefits payable. Facility of Payment. If payments that should have been made under this plan are made by another plan, KFHPWA has the right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. The amounts paid to the other plan are considered benefits paid under this plan. To the extent of such payments, KFHPWA is fully discharged from liability under this plan. Right of Recovery. KFHPWA has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision. KFHPWA may recover excess payment from any person to whom or for whom payment was made or any other issuers or plans. PEBB_VA_2024 68

Questions about Coordination of Benefits? Contact the State Insurance Department. Effect of Medicare. Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status, and will be adjudicated by KFHPWA as set forth in this section. KFHPWA will pay primary to Medicare when required by federal law. When Medicare, Part A and Part B or Part C are primary, Medicare's allowable amount is the highest allowable expense. When a Network Provider renders care to a Enrollee who is eligible for Medicare benefits, and Medicare is deemed to be the primary bill payer under Medicare secondary payer guidelines and regulations, KFHPWA will seek Medicare reimbursement for all Medicare covered services. XI. Subrogation and Reimbursement Rights The benefits under this EOC will be available to a Enrollee for injury or illness caused by another party, subject to the exclusions and limitations of this EOC. If KFHPWA provides benefits under this EOC for the treatment of the injury or illness, KFHPWA will be subrogated to any rights that the Enrollee may have to recover compensation or damages related to the injury or illness and the Enrollee shall reimburse KFHPWA for all benefits provided, from any amounts the Enrollee received or is entitled to receive from any source on account of such injury or illness, whether by suit, settlement or otherwise, including but not limited to: • Payments made by a third party or any insurance company on behalf of the third party; • Any payments or awards under an uninsured or underinsured motorist coverage policy; • Any Workers’ Compensation or disability award or settlement; • Medical payments coverage under any automobile policy, premises or homeowners’ medical payments coverage or premises or homeowners’ insurance coverage; and • Any other payments from a source intended to compensate an Injured Person for injuries resulting from an accident or alleged negligence. This section more fully describes KFHPWA’s subrogation and reimbursement rights. "Injured Person" under this section means an Enrollee covered by the EOC who sustains an injury or illness and any spouse, dependent or other person or entity that may recover on behalf of such Enrollee including the estate of the Enrollee and, if the Enrollee is a minor, the guardian or parent of the Enrollee. When referred to in this section, "KFHPWA's Medical Expenses" means the expenses incurred and the value of the benefits provided by KFHPWA under this EOC for the care or treatment of the injury or illness sustained by the Injured Person. If the Injured Person’s injuries were caused by a third party giving rise to a claim of legal liability against the third party and/or payment by the third party to the Injured Person and/or a settlement between the third party and the Injured Person, KFHPWA shall have the right to recover KFHPWA's Medical Expenses from any source available to the Injured Person as a result of the events causing the injury. This right is commonly referred to as "subrogation." KFHPWA shall be subrogated to and may enforce all rights of the Injured Person to the full extent of KFHPWA's Medical Expenses. By accepting benefits under this plan, the Injured Person also specifically acknowledges KFHPWA’s right of reimbursement. This right of reimbursement attaches when this KFHPWA has provided benefits for injuries or illnesses caused by another party and the Injured Person or the Injured Person’s representative has recovered any amounts from a third party or any other source of recovery. KFHPWA’s right of reimbursement is cumulative with and not exclusive of its subrogation right and KFHPWA may choose to exercise either or both rights of recovery. In order to secure KFHPWA’s recovery rights, the Injured Person agrees to assign KFHPWA any benefits or claims or rights of recovery they may have under any automobile policy or other coverage, to the full extent of the plan’s subrogation and reimbursement claims. This assignment allows KFHPWA to pursue any claim the Injured Person may have, whether or not they choose to pursue the claim. PEBB_VA_2024 69

KFHPWA’s subrogation and reimbursement rights shall be limited to the excess of the amount required to fully compensate the Injured Person for the loss sustained, including general damages. Subject to the above provisions, if the Injured Person is entitled to or does receive money from any source as a result of the events causing the injury or illness, including but not limited to any liability insurance or uninsured/underinsured motorist funds, KFHPWA’s Medical Expenses are secondary, not primary. The Injured Person and their agents shall cooperate fully with KFHPWA in its efforts to collect KFHPWA's Medical Expenses. This cooperation includes, but is not limited to, supplying KFHPWA with information about the cause of injury or illness, any potentially liable third parties, defendants and/or insurers related to the Injured Person's claim. The Injured Person shall notify KFHPWA within 30 days of any claim that may give rise to a claim for subrogation or reimbursement. The Injured Person shall provide periodic updates about any facts that may impact KFHPWA’s right to reimbursement or subrogation as requested by KFHPWA, and shall inform KFHPWA of any settlement or other payments relating to the Injured Person’s injury. The Injured Person and their agents shall permit KFHPWA, at KFHPWA's option, to associate with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or claim filed. The Injured Person and their agents shall do nothing to prejudice KFHPWA’s subrogation and reimbursement rights. The Injured Person shall promptly notify KFHPWA of any tentative settlement with a third party and shall not settle a claim without protecting KFHPWA’s interest. The Injured Person shall provide 21 days advance notice to KFHPWA before there is a disbursement of proceeds from any settlement with a third party that may give rise to a claim for subrogation or reimbursement. If the Injured Person fails to cooperate fully with KFHPWA in recovery of KFHPWA’s Medical Expenses, and such failure prejudices KFHPWA’s subrogation and/or reimbursement rights, the Injured Person shall be responsible for directly reimbursing KFHPWA for 100% of KFHPWA’s Medical Expenses. To the extent that the Injured Person recovers funds from any source that in any manner relate to the injury or illness giving rise to KFHPWA’s right of reimbursement or subrogation, the Injured Person agrees to hold such monies in trust or in a separate identifiable account until KFHPWA’s subrogation and reimbursement rights are fully determined and that KFHPWA has an equitable lien over such monies to the full extent of KFHPWA’s Medical Expenses and/or the Injured Person agrees to serve as constructive trustee over the monies to the extent of KFHPWA’s Medical Expenses. In the event that such monies are not so held, the funds are recoverable even if they have been comingled with other assets, without the need to trace the source of the funds. Any party who distributes funds without regard to KFHPWA’s rights of subrogation or reimbursement will be personally liable to KFHPWA for the amounts so distributed. If reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining recovery, KFHPWA will reduce the amount of reimbursement to KFHPWA by the amount of an equitable apportionment of such collection costs between KFHPWA and the Injured Person. This reduction will be made only if each of the following conditions has been met: (i) KFHPWA receives a list of the fees and associated costs before settlement and (ii) the Injured Person’s attorney’s actions were directly related to securing recovery for the Injured Party to the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, implementation of this section shall be deemed a part of claims administration and KFHPWA shall therefore have discretion to interpret its terms. XII. Definitions Allowance The maximum amount payable by KFHPWA for certain Covered Services. Allowed Amount The level of benefits which are payable by KFHPWA when expenses are incurred from a non-Network Provider. Expenses are considered an Allowed Amount if the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies; and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. Enrollees shall be required to pay any difference between a non-Network Provider’s PEBB_VA_2024 70

charge for services and the Allowed Amount, except for Emergency services, including post stabilization and for ancillary services received from an out of network provider in a network facility. For more information about balance billing protections, please visit: https://healthy.kaiserpermanente.org/washington/support/forms and click on the “Billing forms” link. Annual Open A period of time defined by HCA when a Subscriber may change to another health plan Enrollment offered by the PEBB Program and make certain other account changes for an effective date beginning January 1 of the following year. Continuation Coverage Temporary continuation of PEBB benefits available to Enrollees under the Consolidated Omnibus Budget Reconciliation Act (COBRA), the Uniformed Services Employment and Reemployment Rights Act (USERRA), or PEBB policies. Convalescent Care Care furnished for the purpose of meeting non-medically necessary personal needs which could be provided by persons without professional skills or training, such as assistance in walking, dressing, bathing, eating, preparation of special diets, and taking medication. Copayment The specific dollar amount an Enrollee is required to pay at the time of service for certain Covered Services. Cost Share The portion of the cost of Covered Services for which the Enrollee is liable. Cost Share includes Copayments, coinsurances and Deductibles. Covered Services The services for which an Enrollee is entitled to coverage in the EOC. Creditable Coverage Coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare prescription drug coverage, as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS actuarial guidelines. In general, the actuarial determination measures whether the expected amount of paid claims under KFHPWA’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. Deductible A specific amount an Enrollee is required to pay for certain Covered Services before benefits are payable. Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements as described in the “Dependent Eligibility” section of this EOC, is enrolled hereunder and for whom the premium has been paid. Emergency The emergent and acute onset of a medical, mental health or substance use disorder symptom or symptoms, including but not limited to severe pain or emotional distress, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part, or would place the Enrollee’s health, or if the Enrollee is pregnant, the health of the unborn child, in serious jeopardy, or any other situations which would be considered an emergency under applicable federal or state law. A division, department, or separate agency of state government, including an institution Employing Agency of higher education; a county, municipality, or other political subdivision; and a tribal government covered by HCA statute. PEBB_VA_2024 71

Enrollee Any enrolled Subscriber or Dependent. Essential Health Benefits set forth under the Patient Protection and Affordable Care Act of 2010, Benefits including the categories of ambulatory patient services, Emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care. Established Enrollee must have had at least one in-person appointment or at least one real-time Relationship interactive appointment using both audio and visual technology in the past year, with the provider providing audio only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by KFHPWA. Or the Enrollee was referred to the provider providing audio-only telemedicine by a provider who they have had an in-person appointment within the past year. Evidence of Coverage The EOC is a statement of benefits, exclusions and other provisions as set forth in the (EOC) Group medical coverage agreement between KFHPWA and the Group. Family Unit A Subscriber and all their Dependents. Group An employer, union, welfare trust or bona-fide association which has entered into a Group medical coverage agreement with KFHPWA. Health Care Authority The Washington state agency that administers the PEBB and SEBB Programs. (HCA) Hospital Care Those Medically Necessary services generally provided by acute general hospitals for admitted patients. KFHPWA-designated A specialist specifically identified by KFHPWA. Specialist Medical Condition A disease, illness or injury. Medically Necessary Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed, additional reviews may be conducted. Enrollees will be notified in writing when a determination has been made. Appropriate and clinically necessary services, as determined by KFHPWA’s medical director according to generally accepted principles of good medical practice, which are rendered to an Enrollee for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. In order to be Medically Necessary, services and supplies must meet the following requirements: (a) are not solely for the convenience of the Enrollee, their family member or the provider of the services or supplies; (b) are the most appropriate level of service or supply which can be safely provided to the Enrollee; (c) are for the diagnosis or treatment of an actual or existing Medical Condition unless being provided under KFHPWA’s schedule for preventive services; (d) are not for recreational, life-enhancing, relaxation or palliative therapy, except for treatment of terminal conditions; (e) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Washington, could not have been omitted without adversely affecting the Enrollee’s condition or the quality of health services rendered; (f) as to inpatient care, could not have been provided in a provider’s office, the outpatient department of a hospital or a non-residential facility without affecting the Enrollee’s PEBB_VA_2024 72

condition or quality of health services rendered; (g) are not primarily for research and data accumulation; and (h) are not experimental or investigational. The length and type of the treatment program and the frequency and modality of visits covered shall be determined by KFHPWA’s medical director. In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service and not excluded from coverage. Medicare The federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Network Facility A facility (hospital, medical center or health care center) owned or operated by Kaiser Foundation Health Plan of Washington or otherwise designated by KFHPWA, or with whom KFHPWA has contracted to provide health care services to Enrollees. Network Personal A provider who is employed by Kaiser Foundation Health Plan of Washington or Physician Washington Permanente Medical Group, P.C., or contracted with KFHPWA to provide primary care services to Enrollees and is selected by each Enrollee to provide or arrange for the provision of all non-emergent Covered Services, except for services set forth in the EOC which a Enrollee can access without Preauthorization. Network Personal Physicians must be capable of and licensed to provide the majority of primary health care services required by each Enrollee. Network Provider The medical staff, clinic associate staff and allied health professionals employed by Kaiser Foundation Health Plan of Washington or Washington Permanente Medical Group, P.C., and any other health care professional or provider with whom KFHPWA has contracted to provide health care services to Enrollees, including, but not limited to physicians, podiatrists, nurses, physician assistants, social workers, optometrists, psychologists, physical therapists and other professionals engaged in the delivery of healthcare services who are licensed or certified to practice in accordance with Title 18 Revised Code of Washington. Out-of-pocket Expenses Those Cost Shares paid by the Subscriber or Enrollee for Covered Services which are applied to the Out-of-pocket Limit. Out-of-pocket Limit The maximum amount of Out-of-pocket Expenses incurred and paid during the calendar year for Covered Services received by the Subscriber and their Dependents within the same calendar year. The Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV. Plan Coinsurance The percentage amount the Enrollee is required to pay for Covered Services received. Preauthorization An approval by KFHPWA that entitles an Enrollee to receive Covered Services from a specified health care provider. Services shall not exceed the limits of the Preauthorization and are subject to all terms and conditions of the EOC. Enrollees who have a complex or serious medical or psychiatric condition may receive a standing Preauthorization for specialty care provider services. Private Duty Nursing The hiring of a nurse by a family or Member to provide long term and/or continuous one (or 24-hour nursing on one care with or without oversight by a home health agency. The care may be skilled, care) supportive or respite in nature. Public Employees A group of representatives, appointed by the governor, who approves insurance benefit Benefits Board (PEBB) plans for employees and their dependents, and establishes eligibility criteria for PEBB_VA_2024 73

participation in insurance benefit plans. Public Employees Benefits Board (PEBB) Is the HCA program that administers PEBB benefit eligibility and enrollment. Program Residential Treatment A term used to define facility-based treatment, which includes 24 hours per day, 7 days per week rehabilitation. Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi- disciplinary team of licensed professionals. School Employees A group of representatives, appointed by the governor, who designs and approves Benefits Board (SEBB) insurance benefit plans for school employees and their dependents, and establishes eligibility criteria for participation in insurance benefit plans. School Employees A public school district or educational service district or charter school established under Benefits Board (SEBB) Washington state statute that is required to participate in benefit plans provided by the Organization School Employees Benefits Board (SEBB). School Employees Is the program within HCA that administers insurance and other benefits for eligible Benefits Board (SEBB) school employees and eligible dependents. Program Service Area Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Lewis, Mason, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman and Yakima. State Agency An office, department, board, commission, institution, or other separate unit or division, however designated, of the Washington state government. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education and any unit of state government established by law. Subscriber An employee or continuation coverage enrollee who has been determined eligible and is enrolled in this plan, and is the individual to whom the PEBB Program or Kaiser will issue notices, requests, and premium bills on behalf of an Enrollee. Urgent Condition The sudden, unexpected onset of a Medical Condition that is of sufficient severity to require medical treatment within 24 hours of its onset. PEBB_VA_2024 74