Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) Emergency medical 10% coinsurance 10% coinsurance None transportation Urgent care 10% coinsurance 10% coinsurance Non-network providers covered when temporarily outside the service area. Facility fee (e.g., hospital 10% coinsurance Not covered Preauthorization required or will not be If you have a room) covered. hospital stay Physician/surgeon fees 10% coinsurance Not covered Preauthorization required or will not be covered. If you need mental Outpatient services 10% coinsurance Not covered None health, behavioral health, or substance Inpatient services 10% coinsurance Not covered Preauthorization required or will not be abuse services covered. Cost sharing does not apply for preventive Office visits 10% coinsurance Not covered services. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you are pregnant Childbirth/delivery You must notify Kaiser Permanente within 24 professional services 10% coinsurance Not covered hours of admission, or as soon thereafter as medically possible. Childbirth/delivery facility You must notify Kaiser Permanente within 24 services 10% coinsurance Not covered hours of admission, or as soon thereafter as medically possible. Home health care 10% coinsurance Not covered Preauthorization required or will not be covered. Outpatient: 10% Combined with Habilitation services: Rehabilitation services coinsurance Not covered Outpatient: 60 visit limit / year. Inpatient: 60- If you need help Inpatient: 10% day limit / year, preauthorization required or recovering or have coinsurance will not be covered. other special health Outpatient: 10% Combined with Rehabilitation services: needs Habilitation services coinsurance Not covered Outpatient: 60 visit limit / year. Inpatient: 60- Inpatient: 10% day limit / year, preauthorization required or coinsurance will not be covered. Skilled nursing care 10% coinsurance Not covered 60-day limit / year. Preauthorization required or will not be covered. Page 3 of 6