I. Introduction Note: This is a Health Savings Account (HSA) Qualified Health Plan. The health plan meets all of the requirements to be used in conjunction with an Enrollee-initiated Health Savings Account. The provisions of the Evidence of Coverage (EOC) do not override, or take the place of, any regulatory requirements for Health Savings Accounts. Participation in a health savings account is not a requirement for enrollment or continued eligibility. Kaiser Foundation Health Plan of Washington (“KFHPWA”) is not a trustee, administrator or fiduciary of any Health Savings Account which may be used in conjunction with the EOC. Please contact the Health Savings Account trustee or administrator regarding questions about requirements for Health Savings Accounts. This EOC is a statement of benefits, exclusions and other provisions as set forth in the Group medical coverage agreement between Kaiser Foundation Health Plan of Washington (“KFHPWA”) and the Group. The benefits were approved by the Group who contracts with KFHPWA for health care coverage. This EOC is not the Group medical coverage agreement itself. In the event of a conflict between the Group medical coverage agreement and the EOC, the EOC language will govern. The provisions of the EOC must be considered together to fully understand the benefits available under the EOC. Words with special meaning are capitalized and are defined in Section XII. Contact Kaiser Permanente Member Services at 206-630-0107 or toll-free 1-866-648-1928; for the deaf and hearing-impaired use Washington state’s relay line at 800-833-6388 or 711 for benefits questions. II. How Covered Services Work A. Accessing Care. 1. Enrollees are entitled to Covered Services from the following: Your Provider Network is KFHPWA’s Core Network (Network). Enrollees are entitled to Covered Services only at Core Network Facilities and from Core Network Providers, except for Emergency services and care pursuant to a Preauthorization. Benefits under this EOC will not be denied for any health care service performed by a registered nurse licensed to practice under chapter 18.88 RCW, if first, the service performed was within the lawful scope of such nurse’s license, and second, this EOC would have provided benefit if such service had been performed by a Doctor of Medicine licensed to practice under chapter 18.71 RCW. A listing of Core Network Personal Physicians, specialists, women’s health care providers and KFHPWA- designated Specialists is available by contacting Member Services or accessing the KFHPWA website at www.kp.org/wa. Information available online includes each physician’s location, education, credentials, and specialties. KFHPWA also utilizes Health Care Benefit Managers for certain services. To see a list of Health Care Benefit Managers, go to https://healthy.kaiserpermanente.org/washington/support/forms and click on the “Evidence of coverage” link. KFHPWA will not directly or indirectly prohibit Enrollees from freely contracting at any time to obtain health care services from Non-Network Providers and Non-Network Facilities outside the Plan. However, if you choose to receive services from Non-Network Providers and Non-Network 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 Out-of-Pocket Limit. 2. Primary Care Provider Services. KFHPWA recommends that Enrollees select a Network Personal Physician when enrolling. One personal physician may be selected for an entire family, or a different personal physician may be selected for each family member. For information on how to select or change Network Personal Physicians, and for a list of PEBB HMOHSA 2024 6