Kaiser Permanente WA Value SBC (2024)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024 – 12/31/2024 : PEBB Value Plan Coverage for: Individual / Family | Plan Type: HMO All plans offered and underwritten by Kaiser Foundation Health Plan of Washington The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.kp.org/plandocuments or call 1-888-901-4636 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-888-901- 4636 (TTY: 711) to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before What is the overall $250 Individual / $750 Family this plan begins to pay. If you have other family members on the plan, each family member deductible? must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services This plan covers some items and services even if you haven’t yet met the deductible covered before you meet Yes. Preventive care and services amount. But a copayment or coinsurance may apply. For example, this plan covers certain your deductible? indicated in chart starting on page 2. preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits. Are there other Yes. $100 Individual / $300 Family for You must pay all of the costs for the services up to the specific deductible amount before deductibles for specific prescription drugs. There are no other this plan begins to pay for these services. services? specific deductibles. What is the out-of-pocket $3,000 Individual / $6,000 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other limit for this plan? $2,000 Individual / $8,000 Family for family members in this plan, they have to meet their own out-of-pocket limits until the overall family prescription drugs out-of-pocket limit has been met. Premiums, balance-billing charges, What is not included in health care this plan doesn’t cover, Even though you pay these expenses, they don’t count toward the out-of-pocket limit. the out-of-pocket limit? and services indicated in chart starting on page 2. This plan uses a provider network. You will pay less if you use a provider in the plan’s Will you pay less if you Yes. See www.kp.org or call 1-888- network. You will pay the most if you use an out-of-network provider, and you might receive use a network provider? 901-4636 (TTY: 711) for a list of a bill from a provider for the difference between the provider’s charge and what your plan network providers. pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but only if see a specialist? specialists. you have a referral before you see the specialist. Page 1 of 6 RQ-189958-1

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) Primary care visit to treat $30 / visit Not covered None an injury or illness If you visit a health Specialist visit $50 / visit Not covered None care provider’s office or clinic Preventive You may have to pay for services that aren’t care/screening/ No charge, deductible does Not covered preventive. Ask your provider if the services immunization not apply. needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, No charge Not covered None If you have a test blood work) Imaging (CT/PET scans, $50/visit Not covered Preauthorization required or will not be MRIs) covered. $5 (retail); $10 (mail order) / Value based drugs prescription, deductible does not apply. Up to a 90-day supply (retail / mail order). Not covered Subject to formulary guidelines. If you need drugs to Preferred generic drugs $25 (retail); $50 (mail order) treat your illness or / prescription, deductible condition does not apply. More information Preferred brand drugs $50 (retail); $100 (mail Not covered Up to a 90-day supply (retail / mail order). about prescription order) / prescription Subject to formulary guidelines. drug coverage is Non-preferred drugs 50% coinsurance (retail & Not covered Up to a 90-day supply (retail / mail order). available at mail order) / prescription Subject to formulary guidelines . www.kp.org/formulary Preferred: $150 (retail) / prescription Up to a 30-day supply (retail). Subject to Specialty drugs Not covered formulary guidelines, when approved through Non-preferred: 50% the exception process. coinsurance up to $400 (retail) / prescription If you have Facility fee (e.g., outpatient surgery ambulatory surgery $200 / visit Not covered None center) Page 2 of 6

Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) Physician/surgeon fees No charge Not covered Physician/surgeon fees are included in the Facility fee. You must notify Kaiser Permanente within 24 Emergency room care $300 / visit $300 / visit hours if admitted to a Non-network provider; If you need limited to initial emergency only. immediate medical Emergency medical 20% coinsurance, 20% coinsurance , None attention transportation deductible does not apply. deductible does not apply. Urgent care $30 / visit $300 / visit Non-network providers covered when temporarily outside the service area. Facility fee (e.g., hospital $250 / day up to $1,250 / Not covered Preauthorization required or will not be If you have a room) admission covered. hospital stay Physician/surgeon fees are included in the Physician/surgeon fees No charge Not covered Facility fee. Preauthorization required or will not be covered. If you need mental Outpatient services $30 / visit Not covered None health, behavioral health, or substance Inpatient services $250 / day up to $1,250 / Not covered Preauthorization required or will not be abuse services admission covered. Depending on the type of services, a copayment, coinsurance, or deductible may Office visits No charge Not covered apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you are pregnant Professional services are included in the Childbirth/delivery No charge Not covered Facility services. You must notify Kaiser professional services Permanente within 24 hours of admission, or as soon thereafter as medically possible. Childbirth/delivery facility $250 / day up to $1,250 / You must notify Kaiser Permanente within 24 services admission Not covered hours of admission, or as soon thereafter as medically possible. If you need help Home health care No charge, deductible does Not covered Preauthorization required or will not be recovering or have not apply. covered. other special health Rehabilitation services Outpatient: $50 / visit Not covered Combined with Habilitation services: needs Inpatient: $250 / day up to Outpatient: 60 visit limit / year. Inpatient: 60- Page 3 of 6

Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) $1,250 / admission day limit / year, preauthorization required or will not be covered. Outpatient: $50 / visit Combined with Rehabilitation services: Habilitation services Inpatient: $250 / day up to Not covered Outpatient: 60 visit limit / year. Inpatient: 60- $1,250 / admission day limit / year, preauthorization required or will not be covered. Skilled nursing care $250 / day up to $1,250 / Not covered 150-day limit / year. Preauthorization admission required or will not be covered. Durable medical 20% coinsurance, Subject to formulary guidelines. equipment deductible does not apply. Not covered Preauthorization required or will not be covered. Hospice services No charge, deductible does Not covered Preauthorization required or will not be not apply. covered. Children’s eye exam $30 / visit for refractive Not covered Limited to 1 exam / 12 months exam Member age 19 and over limited to $150 If your child needs Children’s glasses No charge Not covered every 24 months. Members under age 19 dental or eye care limited to 1 pair of frames and lenses / year or contact lenses covered at 50% coinsurance. Children’s dental check- Not covered Not covered None up Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery • Non-emergency care when traveling outside the U.S. • Routine foot care • Infertility treatment • Private-duty nursing • Weight loss programs • Long-term care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (24 visit limit / year) • Chiropractic care (24 visit limit / year) • Routine eye care (Adult) • Bariatric surgery • Hearing aids ($3,000 limit / ear / 36 months) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318- 2596. Page 4 of 6

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the agencies in the chart below. Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Kaiser Permanente Member Services 1-888-901-4636 (TTY: 711) or www.kp.org Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or www.cciio.cms.gov. Washington Department of Insurance 1-800‑562‑6900 or www.insurance.wa.gov Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-888-901-4636 (TTY: 711). Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-901-4636 (TTY: 711). Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-901-4636 (TTY: 711). Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-901-4636 (TTY: 711). To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 5 of 6

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care) ◼ The plan’s overall deductible $250 ◼ The plan’s overall deductible $250 ◼ The plan’s overall deductible $250 ◼ Specialist copayment $50 ◼ Specialist copayment $50 ◼ Specialist copayment $50 ◼ Hospital (facility) copayment $250 ◼ Hospital (facility) copayment $250 ◼ Hospital (facility) copayment $250 ◼ Other (blood work) copayment $0 ◼ Other (blood work) copayment $0 ◼ Other (x-ray) copayment $0 This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical Childbirth/Delivery Professional Services disease education) supplies) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $250 Deductibles $350 Deductibles $250 Copayments $300 Copayments $1,400 Copayments $600 Coinsurance $0 Coinsurance $0 Coinsurance $200 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $20 Limits or exclusions $0 Limits or exclusions $0 The total Peg would pay is $570 The total Joe would pay is $1,750 The total Mia would pay is $1,050 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6