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. The provider network for this Deductible 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. 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. DEFINITIONS Allowed Amount. The lower of the following amounts:  The actual fee the provider, facility, or vendor charged for the Service.  160 percent of the Medicare fee for the Service, as indicated by the applicable Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code shown on the current Medicare fee schedule. The Medicare fee schedule is developed by the Centers for Medicare and Medicaid Services (CMS) and adjusted by Medicare geographical practice indexes. When there is no established CPT or HCPCS code indicating the Medicare fee for a particular Service, the Allowed Amount is 70 percent of the actual fee the provider, facility, or vendor charged for the Service. Ancillary Service. Services that are:  Related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner.  Provided by assistant surgeons, hospitalists, and intensivists.  Diagnostic Services, including radiology and laboratory Services.  Provided by a Non-Participating Provider if there is no Participating Provider who can furnish such Service at the facility.  Provided as a result of unforeseen, urgent medical needs that arise at the time the Service is provided, regardless of whether the Non-Participating Provider or Non-Participating Facility satisfies the notice and consent requirements under federal law. Annual Open Enrollment. A period of time defined by HCA when a Subscriber may change to another health plan offered by the PEBB Program and make certain other account changes for an effective date beginning January 1 of the following year. EWCLGDED1983ACT0124 7 WAPEBB-CL-ACT