INTRODUCTION This Evidence of Coverage (EOC), including the “Benefit Summary,” describes the health care benefits of this Plan provided under the Administrative Services Contract (Contract) between Kaiser Foundation Health Plan of the Northwest and the Washington State Health Care Authority (HCA) for the Public Employees Benefits Board (PEBB) Program. In the event of a conflict in language between the Plan Contract and the EOC, the EOC will govern. For benefits provided under any other Plan, refer to that Plan’s evidence of coverage. This health benefit Plan is a high deductible health Plan that meets the requirements of Section 223 (c)(2) of the Internal Revenue Code. The health care coverage described in this EOC is designed to be compatible for use with a Health Savings Account (HSA) under federal tax law. The tax references contained in this EOC relate to federal income tax only. The tax treatment of HSA contributions and distributions under your state income tax laws may differ from the federal tax treatment and differ from state to state. Kaiser Foundation Health Plan of the Northwest does not provide tax advice. You should consult with your financial or tax advisor for tax advice or more information, including information about your eligibility for an HSA. PEBB may contribute to your HSA, find more information (HCA website). Enrollment in a high deductible health Plan that is HSA-compatible is only one of the eligibility requirements for establishing and contributing to an HSA. Some examples of other requirements include that you must not be:  Covered by another health coverage plan that is not also an HSA-compatible plan, with certain exceptions.  Enrolled in Medicare Part A or Part B.  Able to be claimed as a dependent on another person’s tax return. The provider network for this High Deductible Health Plan is the Classic network. Kaiser Foundation Health Plan of the Northwest uses health care benefit managers to administer this Plan. For a current list of the health care benefit managers, we use and the services they provide, please visit kp.org/disclosures; look under “Choose your region”; select Oregon / SW Washington; click on “Coverage information”; expand the “Getting care” list; and open the document titled List of Health Care Benefit Managers. The provisions of this EOC must be considered together to fully understand the benefits available under the EOC. In this EOC, Kaiser Foundation Health Plan of the Northwest is sometimes referred to as “Kaiser,” “we,” “our,” or “us.” Members are sometimes referred to as “you.” Some capitalized terms have special meaning in this EOC. See the “Definitions” section for terms you should know. Because the Washington State Health Care Authority offers this high deductible health Plan to PEBB’s Members as a “self-only” Plan or as a “family” Plan where dependents are covered, it is important to familiarize yourself with your coverage by reading this EOC and the “Benefit Summary” completely. In some cases, certain provisions in this EOC apply only to the family Plan when dependents are mentioned. Otherwise, the content of this EOC is applicable to both. Also, if you have special health care needs, carefully read the sections applicable to you. It is important to familiarize yourself with your coverage by reading this EOC and the “Benefit Summary” completely, so that you can take full advantage of your Plan benefits. Also, if you have special health care needs, carefully read the sections applicable to you. If you would like additional information about your benefits, important health plan disclosures, or other products or services, please call Member Services or you may also e-mail us by registering at kp.org. EWCLGHDHP1983ACT0124 7 WAPEBB-CD-ACT