Hearing Aid 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. Hearing aids We cover prescription hearing aids, visits to determine the appropriate hearing aid model, visits to verify that the hearing aid conforms to the prescription, and visits for fitting, counseling, adjustment, cleaning, and inspection. These services are covered only when received from network providers. Hearing exams to determine the need for hearing correction and to provide a prescription for hearing aids are not covered under this "Hearing Aid Rider" (see "Hearing services" in the Medical Benefits Chart). We provide an allowance toward the price of a hearing aid or aids. The allowance and your cost- sharing, if any, are listed in the Medical Benefits Chart "Hearing services, Hearing aids" section. You do not have to use the allowance for both ears at the same time, but we will not provide the allowance for an ear if we have previously covered a hearing aid for that ear within the allowance period under this or any other evidence of coverage (including riders) with the same group number printed on the Medical Benefits Chart. The date we cover a hearing aid is the date on which you are fitted for the hearing aid. If you are fitted for a hearing aid while you are covered under this EOC, and if we would otherwise cover the hearing aid, we will cover the hearing aid even if you do not receive the hearing aid until after you are no longer covered under this EOC. Covered hearing aids are electronic devices worn on the person for the purpose of amplifying sound and assisting in the process of hearing, including an ear mold, if necessary, and are limited to one of the following digital models: (i) in-the-ear; (ii) behind-the-ear; (iii) on-the-body (Body Aid Model); or (iv) canal/CIC aids. Hearing aid rider exclusions • Bone anchored hearing aids. • Cleaners, moisture guards, and assistive listening devices (for example, FM systems, cell phone or telephone amplifiers, and personal amplifiers designed to improve your ability to hear in a specific listening situation). • Hearing aids that were fitted before you were covered under this EOC (for example, a hearing aid that was fitted during the previous contract year will not be covered under this EOC, though it might be covered under your evidence of coverage for the previous contract year). • Internally implanted hearing aids. • Non-prescription hearing aids. RSAHA0124 1