choose to receive Services from Non-Participating Providers and Non-Participating 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 Deductible (if any) or Out-of-Pocket Maximum. Primary Care Participating Providers You may select a Primary Care Provider (PCP) at any Participating Medical Office when enrolling in this Plan. One PCP may be selected for the entire Family or a different PCP may be selected for each Family Member. Except for qualifying Emergency Services or authorized referrals, Members must use Participating Facilities. For information about choosing your primary care Participating Provider, please call Member Services or visit kp.org. Female Members also have the option of choosing a women’s health care Participating Provider as their primary care Participating Provider, as long as the women’s health care Participating Provider accepts designation as primary care Participating Provider. A women’s health care Participating Provider must be an obstetrician or gynecologist, a physician assistant specializing in women’s health, an advanced registered nurse practitioner of women’s health, or a certified nurse midwife, practicing within their applicable scope of practice. You may change your primary care Participating Provider at any time by calling Member Services. The change will take effect immediately. Once the Member changes PCPs, any referrals that were made by the previous PCP are valid as long as the referral was authorized by Medical Group. The Member should notify the new PCP that they have been receiving specialty Services from a Participating Provider, so the PCP can make arrangements for the Member to continue to receive specialty Services. Women’s health Care Services Female Members shall have direct and timely access to Participating Providers specializing in women’s health care (WHC) Services. WHC Services are provided by a participating family medicine physician, physician’s assistant, gynecologist, certified nurse midwife, doctor of osteopathy, obstetrician, and advanced registered nurse practitioner, practicing within their applicable scope of practice. Medically appropriate maternity care, including Services for complications of pregnancy (prenatal, delivery, and postnatal care), covered reproductive Services, preventive Services, general examinations, gynecological Services, and follow-up visits are provided to women Members directly from a Participating Provider, without a referral from their PCP. Annual mammograms, including tomosynthesis (3-D mammography), for women 40 years of age or older are covered with or without a referral from a Participating Provider. Mammograms are provided more frequently to women who are at high risk for breast cancer or disease with a Participating Provider referral. We also cover breast examinations, pelvic examinations, and cervical cancer screenings annually for women age 18 or older, and at any time with a referral from your women’s health care Services Participating Provider. Women’s health care Services also include any appropriate Service for other health problems discovered and treated during the course of a visit to a women’s health care Participating Provider for a women’s Service. Referrals Referrals to Participating Providers and Participating Facilities PCPs provide primary medical care, including pediatric care and obstetrics/gynecology care. Specialists provide specialty medical care in areas such as surgery, orthopedics, cardiology, oncology, urology, dermatology, and allergy/immunology. A PCP or Participating Provider will refer you to a Specialist when appropriate. Please call Member Services for information about specialty Services that require a referral or discuss it with your PCP. EWCLGHDHP1983ACT0124 31 WAPEBB-CD-ACT
Kaiser Permanente NW CDHP EOC (2024) Page 37 Page 39