Acupuncture Services Rider Kaiser Permanente Senior Advantage ( HMO) This rider is part of the Kaiser Permanente Senior Advantage (HMO) Evidence of Coverage (EOC) to which it is attached. All provisions of this rider become part of the EOC "Chapter 4: Medical Benefits Chart (what is covered and what you pay)" section. This entire benefit rider is therefore subject to all the terms and provisions of the EOC. We cover the services described in this "Acupuncture Services Rider" when services are received from a network provider and provided as outpatient services in the network provider's office. To locate a network provider, visit www.chpgroup.com. The CHP Group is a network provider we contract with to provide alternative care services. If you need assistance searching for a network provider, or to verify the current participation status of a provider, or if you do not have access to the online directory, please contact Member Services. If a benefit maximum is listed in the Medical Benefits Chart "Alternative care therapies (self- referred)" section, you are responsible for paying the full amount for services after you reach the benefit maximum. Services are subject to any visit limits and applicable cost-sharing listed in the Medical Benefits Chart "Alternative care therapies (self-referred)" section. Acupuncture services Acupuncturists influence the health of the body by the insertion of very fine needles. Acupuncture treatment is primarily used to relieve pain, reduce inflammation, and promote healing. Covered services include: • Evaluation and management. • Acupuncture. • Electro acupuncture. Acupuncture services rider exclusions • Dermal friction technique. • East Asian massage and tui na. • Laserpuncture. • Nambudripad allergy elimination t echnique (NAET). • Point injection therapy. • Qi gong. • Services designed to maintain optimal health in the absence of symptoms. • Sonopuncture. RSAALTC0124 1 A