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Health Maintenance Organization _HMO_ - CalPERS On-Line - State

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					                      Health Maintenance Organization (HMO)
                      Combined Evidence of Coverage and Disclosure Form
                      for the Basic Plan and the Managed Medicare Health Plan

                      Effective January 1, 2010




 Rosa
 tains




Anza-Borrego Desert
     State Park




                      Contracted by the CalPERS Board of Administration
                      Under the Public Employees’ Medical & Hospital Care Act (PEMHCA)
This Disclosure Form and Evidence of Coverage (DF/EOC), the Group Agreement (Agreement), and any
amendments constitute the contract between Kaiser Foundation Health Plan, Inc., and CalPERS. The
Agreement is on file and available for review in the office of the CalPERS Office of Health Plan
Administration, 400 Q St, Sacramento, CA 95811. You may purchase a copy of the Agreement from the
CalPERS Office of Health Plan Administration, P.O. Box 720724, Sacramento, CA 94229-0724, for a
reasonable duplicating charge.

It is in your best interest to familiarize yourself with this DF/EOC. This Combined Disclosure Form and
Evidence of Coverage (DF/EOC) for the Basic Plan and the Managed Medicare Health Plan is divided into
the following sections, which are clearly marked on each page:
• Part One pertains to the Basic Plan;
• Part Two pertains to the Managed Medicare Health Plan, Kaiser Permanente Senior Advantage Plan
     with Part D;
• Part Three provides information about both the Basic Plan and the Managed Medicare Health Plan.

Help in Your Language
Interpreters are available 24 hours a day, seven days a week, at no cost to you. We can also provide you,
your family, and friends with any special assistance needed to access our facilities and services. In addition,
you may be able to get materials written in your language. For more information, call our Member Service
Call Center at 1-800-464-4000 or 1-800-777-1370 (TTY) weekdays from 7 a.m. to 7 p.m., and weekends
from 7 a.m. to 3 p.m.

Ayuda en su propio idioma
Tenemos disponibles intérpretes 24 horas al día, 7 días a la semana, sin ningún costo para usted. También
podemos ofrecerle a usted, sus familiares y sus amigos cualquier tipo de ayuda que necesiten para tener
acceso a nuestras instalaciones y servicios. Además, usted puede obtener materiales escritos en su idioma.
Para más información, llame a nuestro Centro de Llamadas de Servicios a los Miembros al 1-800-788-0616
ó 1-800-777-1370 (TTY) los días de semana de 7 a.m. a 7 p.m., y los fines de semana de 7 a.m. a 3 p.m.
TABLE OF CONTENTS

PART ONE − DISCLOSURE FORM AND EVIDENCE OF COVERAGE FOR
KAISER PERMANENTE BASIC PLAN .................................................................................. 1
BENEFIT CHANGES FOR CURRENT YEAR ............................................................................................ 2
BASIC PLAN BENEFIT SUMMARY .......................................................................................................... 4
INTRODUCTION .......................................................................................................................................... 6
  Term of this DF/EOC.................................................................................................................................. 6
  About Kaiser Permanente............................................................................................................................ 6
PREMIUMS, ELIGIBILITY, AND ENROLLMENT ................................................................................... 8
  Premiums..................................................................................................................................................... 8
  Eligibility..................................................................................................................................................... 9
  Enrollment ................................................................................................................................................. 11
HOW TO OBTAIN SERVICES................................................................................................................... 12
  Routine Care.............................................................................................................................................. 12
  Urgent Care ............................................................................................................................................... 12
  Our Advice Nurses .................................................................................................................................... 12
  Your Personal Plan Physician ................................................................................................................... 13
  Getting a Referral ...................................................................................................................................... 13
  Second Opinions........................................................................................................................................ 16
  Contracts with Plan Providers ................................................................................................................... 17
  Visiting Other Regions .............................................................................................................................. 17
  Your Identification Card............................................................................................................................ 18
  Getting Assistance ..................................................................................................................................... 18
EMERGENCY, POST-STABILIZATION, AND OUT-OF-AREA URGENT CARE FROM
NON–PLAN PROVIDERS .......................................................................................................................... 19
  Prior Authorization.................................................................................................................................... 19
  Emergency Care ........................................................................................................................................ 19
  Post-Stabilization Care .............................................................................................................................. 19
  Out-of-Area Urgent Care........................................................................................................................... 20
  Follow-up Care.......................................................................................................................................... 20
  Payment and Reimbursement .................................................................................................................... 20
  Copayments and Coinsurance ................................................................................................................... 21
BENEFITS, COPAYMENTS, AND COINSURANCE............................................................................... 22
  Copayments and Coinsurance ................................................................................................................... 23
  Preventive Care Services........................................................................................................................... 24
  Outpatient Care.......................................................................................................................................... 25
  Hospital Inpatient Care.............................................................................................................................. 26
  Ambulance Services .................................................................................................................................. 27
  Chemical Dependency Services ................................................................................................................ 27
  Dental Services for Radiation Treatment and Dental Anesthesia ............................................................. 28
  Dialysis Care ............................................................................................................................................. 28
  Durable Medical Equipment for Home Use.............................................................................................. 29
  Health Education ....................................................................................................................................... 30
  Hearing Services........................................................................................................................................ 30
  Home Health Care ..................................................................................................................................... 31
 Hospice Care ............................................................................................................................................. 31
 Infertility Services ..................................................................................................................................... 32
 Mental Health Services.............................................................................................................................. 33
 Ostomy and Urological Supplies............................................................................................................... 33
 Outpatient Imaging, Laboratory, and Special Procedures......................................................................... 34
 Outpatient Prescription Drugs, Supplies, and Supplements ...................................................................... 34
 Prosthetic and Orthotic Devices ................................................................................................................ 37
 Reconstructive Surgery ............................................................................................................................. 38
 Services Associated with Clinical Trials ................................................................................................... 39
 Skilled Nursing Facility Care .................................................................................................................... 40
 Transplant Services ................................................................................................................................... 40
EXCLUSIONS, LIMITATIONS, COORDINATION OF BENEFITS, AND REDUCTIONS................... 42
 Exclusions ................................................................................................................................................. 42
 Limitations................................................................................................................................................. 44
 Coordination of Benefits (COB) ............................................................................................................... 45
 Reductions ................................................................................................................................................. 45
REQUESTS FOR PAYMENT OR SERVICES........................................................................................... 48
 Requests for Payment ................................................................................................................................ 48
 Requests for Services ................................................................................................................................ 49
DISPUTE RESOLUTION ............................................................................................................................ 51
 Grievances ................................................................................................................................................. 51
 Supporting Documents .............................................................................................................................. 52
 Who May File............................................................................................................................................ 52
 DMHC Complaints.................................................................................................................................... 52
 Independent Medical Review (IMR)......................................................................................................... 53
 CalPERS Administrative Review.............................................................................................................. 54
 Binding Arbitration ................................................................................................................................... 55
TERMINATION OF MEMBERSHIP.......................................................................................................... 59
 Termination Due to Loss of Eligibility ..................................................................................................... 59
 Termination of Agreement......................................................................................................................... 59
 Termination for Cause............................................................................................................................... 59
 Termination of a Product or all Products .................................................................................................. 60
 HIPPA Certificates of Creditable Coverage.............................................................................................. 60
 Payments after Termination ...................................................................................................................... 60
 State Review of Membership Termination................................................................................................ 60
CONTINUATION OF MEMBERSHIP ....................................................................................................... 61
 Continuation of Group Coverage .............................................................................................................. 61
 Conversion from Group Membership to an Individual Plan ..................................................................... 65

PART TWO − DISCLOSURE FORM AND EVIDENCE OF COVERAGE FOR
KAISER PERMANENTE SENIOR ADVANTAGE................................................................. 67
BENEFIT CHANGES FOR CURRENT YEAR .......................................................................................... 68
KAISER PERMANENTE SENIOR ADVANTAGE BENEFIT SUMMARY............................................ 70
INTRODUCTION ........................................................................................................................................ 72
  Term of this DF/EOC................................................................................................................................ 72
  About Kaiser Permanente.......................................................................................................................... 72
PREMIUMS, ELIGIBILITY, AND ENROLLMENT ................................................................................. 74
 Premiums................................................................................................................................................... 74
 Eligibility................................................................................................................................................... 75
 Enrollment ................................................................................................................................................. 78
HOW TO OBTAIN SERVICES................................................................................................................... 79
 Routine Care.............................................................................................................................................. 79
 Urgent Care ............................................................................................................................................... 79
 Our Advice Nurses .................................................................................................................................... 80
 Your Personal Plan Physician ................................................................................................................... 80
 Getting a Referral ...................................................................................................................................... 80
 Second Opinions........................................................................................................................................ 82
 Contracts with Plan Providers ................................................................................................................... 83
 Visiting Other Regions .............................................................................................................................. 83
 Your Identification Card............................................................................................................................ 84
 Getting Assistance ..................................................................................................................................... 84
 Member Services ....................................................................................................................................... 84
 Interpreter services .................................................................................................................................... 84
EMERGENCY, POST-STABILIZATION, AND URGENT CARE FROM NON–PLAN
PROVIDERS ................................................................................................................................................ 85
 Prior Authorization.................................................................................................................................... 85
 Emergency Care ........................................................................................................................................ 85
 Post-Stabilization Care .............................................................................................................................. 85
 Urgent Care ............................................................................................................................................... 86
 Follow-up Care.......................................................................................................................................... 86
 Payment and Reimbursement .................................................................................................................... 86
 How to file a claim .................................................................................................................................... 86
BENEFITS, COPAYMENTS, AND COINSURANCE............................................................................... 88
 Copayments and Coinsurance ................................................................................................................... 89
 Special Note about Clinical Trials............................................................................................................. 90
 Outpatient Care.......................................................................................................................................... 91
 Hospital Inpatient Care.............................................................................................................................. 92
 Ambulance Services .................................................................................................................................. 93
 Chemical Dependency Services ................................................................................................................ 93
 Chiropractic Services................................................................................................................................. 94
 Dental Services for Radiation Treatment and Dental Anesthesia ............................................................. 94
 Dialysis Care ............................................................................................................................................. 95
 Durable Medical Equipment for Home Use.............................................................................................. 95
 Health Education ....................................................................................................................................... 96
 Hearing Services........................................................................................................................................ 97
 Home Health Care ..................................................................................................................................... 97
 Hospice Care ............................................................................................................................................. 98
 Infertility Services ..................................................................................................................................... 99
 Mental Health Services.............................................................................................................................. 99
 Ostomy and Urological Supplies............................................................................................................. 100
 Outpatient Imaging, Laboratory, and Special Procedures....................................................................... 101
 Outpatient Prescription Drugs, Supplies, and Supplements .................................................................... 101
 Prosthetic and Orthotic Devices .............................................................................................................. 109
 Reconstructive Surgery ........................................................................................................................... 111
 Religious Nonmedical Health Care Institution Services ......................................................................... 111
 Skilled Nursing Facility Care .................................................................................................................. 112
 Transplant Services ................................................................................................................................. 112
 Vision Services........................................................................................................................................ 113
EXCLUSIONS, LIMITATIONS, COORDINATION OF BENEFITS, AND REDUCTIONS................. 115
 Exclusions ............................................................................................................................................... 115
 Limitations............................................................................................................................................... 117
 Coordination of Benefits ......................................................................................................................... 117
 Reductions ............................................................................................................................................... 118
GRIEVANCES ........................................................................................................................................... 121
 Special note about hospice care............................................................................................................... 121
 Filing a Grievance ................................................................................................................................... 122
 CalPERS Administrative Review............................................................................................................ 123
 Binding Arbitration ................................................................................................................................. 123
REQUESTS FOR SERVICES OR PAYMENT, COMPLAINTS, AND MEDICARE
APPEAL PROCEDURES .......................................................................................................................... 127
 PART 1. Requests for Part C Services and Part D Drugs or Payment .................................................... 127
 Appeal Level 1: Appeal to our Plan ........................................................................................................ 131
 Appeal Level 2: Independent Review Entity (IRE)................................................................................. 134
 Appeal Level 3: Administrative Law Judge (ALJ) ................................................................................. 135
 Appeal Level 4: Medicare Appeals Council (MAC)............................................................................... 135
 PART 2. Complaints (Appeals) if You Think You are Being Discharged From the Hospital Too Soon136
 PART 3. Complaints (Appeals) If You Think Coverage for Your SNF, HHA, or CORF Services is
 Ending Too Soon..................................................................................................................................... 139
TERMINATION OF MEMBERSHIP........................................................................................................ 142
 Termination Due to Loss of Eligibility ................................................................................................... 142
 Termination of Agreement....................................................................................................................... 143
 Disenrolling from Senior Advantage....................................................................................................... 143
 Termination of Contract with CMS......................................................................................................... 143
 Termination for Cause............................................................................................................................. 144
 Termination of a Product or all Products ................................................................................................ 144
 Payments after Termination .................................................................................................................... 144
 Review of Membership Termination....................................................................................................... 144
CONTINUATION OF MEMBERSHIP ..................................................................................................... 145
 Continuation of Group Coverage ............................................................................................................ 145
 Conversion from Group Membership to an Individual Plan ................................................................... 145
ASH PLANS CHIROPRACTIC SERVICES............................................................................................. 147
 Definitions ............................................................................................................................................... 147
 Participating Providers ............................................................................................................................ 148
 Covered Services ..................................................................................................................................... 148
 Member Services ..................................................................................................................................... 149
 Exclusions and Limitations ..................................................................................................................... 149
HELPFUL PHONE NUMBERS AND RESOURCES............................................................................... 151
 Other Important Contacts ........................................................................................................................ 152

PART THREE − DISCLOSURE FORM AND EVIDENCE OF COVERAGE FOR
KAISER PERMANENTE BASIC PLAN AND KAISER PERMANENTE
SENIOR ADVANTAGE ....................................................................................................... 154
MISCELLANEOUS PROVISIONS........................................................................................................... 155
PLAN FACILITIES.................................................................................................................................... 158
  Plan Hospitals and Plan Medical Offices ................................................................................................ 158
  Northern California Region Plan Facilities ............................................................................................. 158
  Southern California Region Plan Facilities ............................................................................................. 160
  Your Guidebook to Kaiser Permanente Services (Your Guidebook) ...................................................... 164
DEFINITIONS............................................................................................................................................ 165
SERVICE AREA ........................................................................................................................................ 170
  Northern California Region Service Area ............................................................................................... 170
  Southern California Region Service Area ............................................................................................... 170

APPENDIX - PREVENTIVE SCREENINGS AND VACCINES............................................ 173
 Children and Teens.................................................................................................................................. 173
 Adults ...................................................................................................................................................... 174
                                                                                               Part One − Basic Plan
Kaiser Foundation Health Plan, Inc.
Northern and Southern California Regions




PART ONE − DISCLOSURE FORM AND EVIDENCE OF
COVERAGE FOR KAISER PERMANENTE BASIC PLAN




January 1, 2010, through December 31, 2010




                                             Member Service Call Center
                                             800-464-4000 toll free
                                             800-777-1370 (TTY for the
                                                hearing/speech impaired) toll free
                                             Weekdays 7 a.m.–7 p.m. and
                                                weekends 7 a.m.–3 p.m. (except holidays)
                                             kp.org




                                                                                           1
BENEFIT CHANGES FOR CURRENT YEAR

The following is a summary of the most important coverage changes and clarifications that we have made
to this Basic Plan 2010 Disclosure Form and Evidence of Coverage (DF/EOC). Please read this DF/EOC
for the complete text of these changes, as well as changes not listed in the summary below. In addition,
please refer to the “Premiums” section for information about 2010 Premiums.

Please refer to the “Benefits, Copayments, and Coinsurance” section in this DF/EOC for benefit
descriptions and the amount Members must pay for covered benefits. Benefits are also subject to the
“Emergency, Post-Stabilization, and Out-of-Area Urgent Care from Non–Plan Providers” and the
“Exclusions, Limitations, Coordination of Benefits, and Reductions” sections in Part One of this DF/EOC.

Bariatric surgery
Medical Group no longer requires prior authorization for bariatric surgery provided by a Plan Physician.
However, if Medical Group refers a Member to a Non–Plan Physician for bariatric surgery, the Services
must be authorized in accord with the authorization procedure for Services not available from Plan
Providers.

Chiropractic care
Chiropractic care is no longer a covered benefit for Basic Plan members effective January 1, 2010.
CalPERS has made this change to make your coverage consistent with coverage offered by other
participating health plans.

Infertility services
Amounts you pay for Services described in the “Infertility Services” section no longer apply to the annual
out-of-pocket maximum. We are making this change to align infertility Services with all other
supplemental benefits, which do not apply toward the annual out-of-pocket maximum.

Members with Medicare
We have revised the “Members with Medicare” section to indicate that if you are eligible for Medicare Part
B but are not eligible for Medicare Part A without cost, you do not have to enroll in a CalPERS Medicare
health plan but you may have the option to do so if you enroll in Medicare Part B.

Mental health and chemical dependency services
In response to the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act,
mental health and chemical dependency benefits no longer have limits on the number of outpatient visits or
inpatient days. Also, transitional residential recovery services are covered at “no charge” for consistency
with other inpatient mental health and chemical dependency services.

Outpatient prescription drugs, supplies, and supplements
Your Copayment has changed. Please refer to the “Outpatient Prescription Drugs, Supplies, and
Supplements” section for specific changes to your Copayments and day limits. CalPERS has made this
change to make your coverage consistent with coverage offered by other participating health plans.



2
Oral nutrition
We have added an exclusion for outpatient oral nutrition to clarify that items such as dietary supplements,
herbal supplements, weight loss aids, formulas, and food are not covered. The exclusion does not apply to




                                                                                                                  Part One − Basic Plan
amino acid-modified products and elemental dietary enteral formula covered under the outpatient
prescription drug benefit, or to enteral formula covered under the “Prosthetic and Orthotic Devices”
section.

Sacramento pricing area
We have separated the Sacramento and Bay Area pricing area into two pricing areas. The Sacramento
pricing area will include the following counties; El Dorado, Placer and Sacramento, all other counties
remain part of the Bay Area pricing area.




                                                                                                              3
BASIC PLAN BENEFIT SUMMARY

Service                                                   You Pay
Professional Services (Plan Provider office visits)
Routine preventive care:
   Physical exams                                         No charge
   Well-child visits (through age 23 months)              No charge
   Family planning visits                                 $15 per visit
   Scheduled prenatal care and first postpartum visit     No charge
   Eye refraction exams                                   No charge
   Hearing tests                                          No charge
Primary and specialty care visits                         $15 per visit
Urgent care visits                                        $15 per visit
Physical, occupational, and speech therapy                $15 per visit
Outpatient Services
Outpatient surgery and certain other outpatient
procedures                                                $15 per procedure
Allergy injection visits                                  No charge
Allergy testing visits                                    $15 per visit
Acupuncture when performed by a Plan Physician            $15 per visit
Biofeedback                                               $15 per visit
Vaccines (immunizations)                                  No charge
X-rays and lab tests                                      No charge
Health education:
Individual visits                                         $15 per visit
   Group educational programs                             No charge
Hospitalization Services
Room and board, surgery, anesthesia, X-rays, lab tests,
and drugs                                                 No charge
Emergency Health Coverage
Emergency Department visits                               $50 for Emergency Department visits
                                                          (does not apply if you are held for observation
                                                          in a hospital unit outside the Emergency
                                                          Department or if admitted directly to the
                                                          hospital as an inpatient)
Ambulance Services
Ambulance Services                                        No charge
Prescription Drug Coverage
Most covered outpatient items in accord with our drug
formulary guidelines from Plan Pharmacies or from our
mail-order service:
Generic items from a Plan Pharmacy                        $5 for up to a 30-day supply, $10 for a 31- to
                                                          60-day supply, or $15 for a 61- to 100-day
                                                          supply

4
Service                                                     You Pay
Generic refills from our mail-order service                 $5 for up to a 30-day supply or $10 for a 31- to
                                                            100-day supply




                                                                                                               Part One − Basic Plan
Brand-name items from a Plan Pharmacy                       $15 for up to a 30-day supply, $30 for a 31- to
                                                            60-day supply, or $45 for a 61- to 100-day
                                                            supply
Brand-name refills from our mail-order service              $15 for up to a 30-day supply or $30 for a 31-
                                                            to 100-day supply
Durable Medical Equipment (DME)
Covered DME for home use in accord with our DME
formulary guidelines                                        No charge
Mental Health Services
Inpatient psychiatric hospitalization                       No charge
Outpatient visits:
Individual and group visits                                 $15 per individual visit
                                                            $7 per group visit
Chemical Dependency Services
Inpatient detoxification                                    No charge
Outpatient individual visits                                $15 per visit
Outpatient group visits                                     $5 per visit
Home Health Services
Home health care                                            No charge
Other
Hearing aid(s)                                              $1,000 Allowance (every 36 months)
Skilled Nursing Facility care (up to 100 days per benefit
period)                                                     No charge
All covered Services related to infertility treatment       50% Coinsurance
Hospice care                                                No charge
Eyeglasses and contact lenses following cataract surgery    $150 Allowance

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,
Copayments and Coinsurance, out-of-pocket maximums, exclusions, or limitations, nor does it list all
benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the “Benefits,
Copayments, and Coinsurance” and “Exclusions, Limitations, Coordination of Benefits, and Reductions”
sections.




                                                                                                           5
INTRODUCTION

Part One and Part Three of this Disclosure Form      Term of this DF/EOC
and Evidence of Coverage (DF/EOC) describe
                                                     This DF/EOC is for the period January 1, 2010,
the health care coverage of the “Basic Plan”
                                                     through December 31, 2010, unless amended.
provided under the Group Agreement
                                                     Your Health Benefits Officer (or, if you are
(Agreement) between Health Plan (Kaiser
                                                     retired, the CalPERS Office of Employer and
Foundation Health Plan, Inc., Northern California
                                                     Member Health Services) can tell you whether
Region and Southern California Region) and your
                                                     this DF/EOC is still in effect and give you a
Group (CalPERS). For benefits provided under
                                                     current one if this DF/EOC has expired or been
any other Health Plan program, refer to that
                                                     amended.
plan’s evidence of coverage.
                                                     About Kaiser Permanente
In this DF/EOC, Health Plan, is sometimes
referred to as “we” or “us.” Members are             Kaiser Permanente provides Services directly to
sometimes referred to as “you.” Some capitalized     our Members through an integrated medical care
terms have special meaning in this DF/EOC;           program. Health Plan, Plan Hospitals, and the
please see the “Definitions” section in Part Three   Medical Group work together to provide our
of this DF/EOC for terms you should know.            Members with quality care. Our medical care
                                                     program gives you access to all of the covered
When you join Kaiser Permanente, you are             Services you may need, such as routine care with
enrolling in one of two Health Plan Regions in       your own personal Plan Physician, hospital care,
California (either our Northern California Region    laboratory and pharmacy Services, Emergency
or Southern California Region), which we call        Care, Urgent Care, and other benefits described
your “Home Region.” The Service Area of each         in the “Benefits, Copayments, and Coinsurance”
Region is described in the “Definitions” section     section. Plus, our healthy living (health
in Part Three of this DF/EOC. The coverage           education) programs offer you great ways to
information in this DF/EOC applies when you
                                                     protect and improve your health.
obtain care in your Home Region. When you visit
the other California Region, you may receive care
as described in “Visiting Other Regions” in the      We provide covered Services to Members using
“How to Obtain Services” section.                    Plan Providers located in your Home Region’s
                                                     Service Area, which is described in the
Please read the following information so that        “Definitions” section in Part Three of this
you will know from whom or what group of             DF/EOC. You must receive all covered care from
providers you may get health care. It is             Plan Providers inside your Home Region’s
important to familiarize yourself with your          Service Area, except as described in the sections
coverage by reading Parts One and Three of this      listed below for the following Services:
DF/EOC completely, so that you can take full         • Authorized referrals as described under
advantage of your Health Plan benefits. Also, if       “Getting a Referral” in the “How to Obtain
you have special health care needs, please             Services” section
carefully read the sections that apply to you.       • Durable medical equipment as described under
                                                       “Durable Medical Equipment for Home Use”
                                                       in the “Benefits, Copayments, and
                                                       Coinsurance” section


6
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


• Emergency ambulance Services as described      • Ostomy and urological supplies as described
  under “Ambulance Services” in the “Benefits,     under “Ostomy and Urological Supplies” in




                                                                                                    Part One − Basic Plan
  Copayments, and Coinsurance” section             the “Benefits, Copayments, and Coinsurance”
• Emergency Care, Post-Stabilization Care, and     section
  Out-of-Area Urgent Care as described in the    • Prosthetic and orthotic devices as described
  “Emergency, Post-Stabilization, and Out-of-      under “Prosthetic and Orthotic Devices” in the
  Area Urgent Care from Non–Plan Providers”        “Benefits, Copayments, and Coinsurance”
  section                                          section
• Home health care as described under “Home
  Health Care” in the “Benefits, Copayments,
  and Coinsurance” section
• Hospice care as described under “Hospice
  Care” in the “Benefits, Copayments, and
  Coinsurance” section




                                                                                                7
PREMIUMS, ELIGIBILITY, AND ENROLLMENT

Premiums                                              Bay Area pricing area. If you live or work in
                                                      these counties: Alameda, Amador, Contra Costa,
Your Group is responsible for paying Premiums.
                                                      Marin, Napa, Nevada, San Francisco, San
If you are responsible for any contribution to the
                                                      Joaquin, San Mateo, Santa Clara, Santa Cruz,
Premiums, your Group will tell you the amount
                                                      Solano, Sonoma, Sutter, Yolo, and Yuba, the
and how to pay your Group (through payroll
                                                      monthly Premiums are:
deduction, for example).
                                                       Bay Area                       Monthly
State employees and annuitants
                                                                                      Premiums
The Premiums listed below will be reduced by           Self only                      $532.56
the amount the state of California contributes         Self and one Dependent         $1065.12
toward the cost of your health benefit plan. These
                                                       Self and two or more           $1384.66
contribution amounts are subject to change as a
                                                       Dependents
result of collective bargaining agreements or
legislative action. Any such change will be
                                                      Sacramento pricing area. If you live or work in
accomplished by the State Controller or affected
                                                      these counties: El Dorado, Placer or Sacramento,
retirement system without any action on your
                                                      the monthly Premiums are:
part. For current contribution information, contact
your Health Benefits Officer (or, if you are
                                                       Sacramento                     Monthly
retired, the CalPERS Office of Employer and
                                                                                      Premiums
Member Health Services).
                                                       Self only                      $502.56
                                                       Self and one Dependent         $1005.12
 State employees and              Monthly
 annuitants                       Premiums             Self and two or more           $1306.66
                                                       Dependents
 Self only                        $494.99
 Self and one Dependent           $989.98
                                                      Other Northern California counties pricing
 Self and two or more             $1286.97
                                                      area. If you live or work in these counties:
 Dependents
                                                      Alpine, Butte, Calaveras, Colusa, Del Norte,
                                                      Glenn, Humboldt, Lake, Lassen, Mariposa,
Contracting agency employees and annuitants
                                                      Mendocino, Merced, Modoc, Mono, Monterey,
The Premiums listed below will be reduced by          Plumas, San Benito, Shasta, Sierra, Siskiyou,
the amount your contracting agency contributes        Stanislaus, Tehama, Trinity, and Tuolumne, the
toward the cost of your health benefit plan. This     monthly Premiums are:
amount varies among contracting agencies. For
assistance on calculating your net contribution,       Other Northern California      Monthly
contact your Health Benefits Officer (or, if you       counties                       Premiums
are retired, the CalPERS Office of Employer and        Self only                      $539.49
Member Health Services). There are five
                                                       Self and one Dependent         $1078.98
geographic pricing areas. The Premiums that
                                                       Self and two or more           $1402.67
apply to you are based on your CalPERS address
                                                       Dependents
of record.



8
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Los Angeles pricing area. If you live or work in     explanation of specific enrollment and eligibility
Los Angeles, San Bernardino, or Ventura              criteria, please consult your Health Benefits




                                                                                                          Part One − Basic Plan
counties, the monthly Premiums are:                  Officer (or, if you are retired, the CalPERS
                                                     Office of Employer and Member Health
 Los Angeles area                Monthly             Services).
                                 Premiums
 Self only                       $413.17             Information pertaining to eligibility, enrollment,
 Self and one Dependent          $826.34             termination of coverage, and conversion rights
 Self and two or more            $1074.24            can be obtained through the CalPERS Web site at
 Dependents                                          www.calpers.ca.gov or by calling CalPERS.
                                                     Also, please refer to the CalPERS Health
Other Southern California counties pricing           Program Guide for information about eligibility.
area. If you live or work in these counties:         It is your responsibility to stay informed about
Fresno, Imperial, Inyo, Kern, Kings, Madera,         your coverage. If you have any questions, contact
Orange, Riverside, San Diego, San Luis Obispo,       your:
Santa Barbara, and Tulare, the monthly               • Health Benefits Officer in your agency
Premiums are:
                                                     • If you are retired, the CalPERS Office of
                                                       Employer and Member Health Services, P.O.
 Other Southern California       Monthly               Box 942714, Sacramento, CA 94229-2714.
 counties                        Premiums              Fax number: 916-795-1277
 Self only                       $454.99
 Self and one Dependent          $909.98             • CalPERS Customer Service and Education
                                                       Division toll free at: 888-CalPERS
 Self and two or more            $1182.97
                                                       (888-225-7377) TTY users call 800-735-2929
 Dependents
                                                       or 916-795-3240
Out of State pricing area. If you live or work
                                                     Group Eligibility Requirements
outside California, the monthly Premiums are:
                                                     You must meet CalPERS eligibility requirements.
 Out of State                    Monthly             Active employees should contact their Health
                                 Premiums            Benefits Officer (or, if you are retired, the
 Self only                       $724.69             CalPERS Office of Employer and Member
 Self and one Dependent          $1449.38            Health Services) to learn about your Group health
                                                     care options.
 Self and two or more            $1884.19
 Dependents
                                                     Service Area Eligibility Requirements
Eligibility                                          Active employees (and annuitants who are
                                                     currently working and enrolled in the Basic Plan)
To enroll and to continue enrollment, you must       must live or work inside his or her Home
meet all of the eligibility requirements described   Region’s Service Area at the time he or she
in this “Eligibility” section. The CalPERS Health    enrolls. The “Definitions” section in Part Three
Program enrollment and eligibility requirements      of this DF/EOC describes your Home Region’s
are determined in accord with the Public             Service Area and how it may change.
Employees’ Medical & Hospital Care Act
(PEMHCA) and the Health Insurance Portability        If you move outside your Home Region’s Service
and Accountability Act (HIPAA). For an               Area after enrollment, you may not be eligible to

                                                                                                      9
continue enrollment. Please contact your Health     in this DF/EOC applies when you obtain care in
Benefits Officer (or, if you are retired, the       your Home Region. When you visit the other
CalPERS Office of Employer and Member               California Region, you may receive care as
Health Services) to learn about your Group health   described in “Visiting Other Regions” in the
care options.                                       “How to Obtain Services” section.

Regions outside California. If you live in or       If you live in or are moving to the other
move to the service area of a Region outside        California Region’s Service Area, please contact
California, you are not eligible for membership     your Health Benefits Officer (or, if you are
under this DF/EOC (unless you are a Subscriber      retired, the CalPERS Office of Employer and
who works inside your Home Region’s Service         Member Health Services) to learn about your
Area or you are a Dependent child of the            Group health care options. CalPERS may have an
Subscriber or of the Subscriber’s Spouse). Please   arrangement with us that permits membership in
contact your Health Benefits Officer (or, if you    the other California Region.
are retired, the CalPERS Office of Employer and
Member Health Services) to learn about your         Members with Medicare
Group health care options. You may be able to       In accord with the Public Employees’ Medical &
enroll in the new service area if there is an       Hospital Care Act (PEMHCA), if you are or
agreement between CalPERS and that Region,          become Medicare-eligible and do not enroll in
but the plan, including coverage, premiums, and     Medicare Part B and a CalPERS Medicare health
eligibility requirements, might not be the same.    plan, CalPERS health coverage for you and all
                                                    your enrolled Dependents will be terminated.
For the purposes of this eligibility rule, the
service areas of the Regions outside California     If you become eligible for Medicare Part B and
may change on January 1 of each year and are        are retired, you must enroll in Kaiser Permanente
currently the District of Columbia and parts of     Senior Advantage with Part D, if you are eligible
Colorado, Georgia, Hawaii, Idaho, Maryland,         as described in Part Two of this DF/EOC, to
Ohio, Oregon, Virginia, and Washington. For         continue Kaiser Permanente membership.
more information, please call our Member
Service Call Center.                                Medicare late enrollment penalties. If you
                                                    become eligible for Medicare Part B and do not
Note: You may be able to receive certain care if    enroll, Medicare may require you to pay a late
you are visiting the service area of another        enrollment penalty if you later enroll in Medicare
Region. See “Visiting Other Regions” in the         Part B. However, if you delay enrollment in Part
“How to Obtain Services” section for                B because you or your husband or wife are still
information.                                        working and have coverage through an employer
                                                    group health plan, you may not have to pay the
Our Northern and Southern California
                                                    penalty. Also, if you are or become eligible for
Regions’ Service Areas. When you join Kaiser
                                                    Medicare and go without creditable prescription
Permanente, you are enrolling in one of two
                                                    drug coverage (drug coverage that is at least as
Health Plan Regions in California (either our
                                                    good as the standard Medicare Part D
Northern California Region or Southern
                                                    prescription drug coverage) for a continuous
California Region), which we call your “Home
                                                    period of 63 days or more, you may have to pay a
Region.” The Service Area of each Region is
                                                    late enrollment penalty if you later sign up for
described in the “Definitions” section in Part
                                                    Medicare prescription drug coverage. If you are
Three of this DF/EOC. The coverage information
                                                    or become eligible for Medicare, your Group is
10
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


responsible for informing you about whether your     Also, if you choose to use your work address as
drug coverage under this DF/EOC is creditable        the ZIP code when you enroll, you must complete




                                                                                                            Part One − Basic Plan
prescription drug coverage at the time required by   the “CalPERS Employer ZIP code Election
CMS and upon your request.                           Form.” To obtain this form, please contact your
                                                     Health Benefits Officer (or, if you are retired, the
Enrollment
                                                     CalPERS Office of Employer and Member
To enroll in this Plan, use form CalPERS             Health Services).
HBD-12. Your agency Health Benefits Officer
(or, if you are retired, the CalPERS Office of       Effective date of coverage
Employer and Member Health Services) can
                                                     Your coverage begins on the date established by
provide both the form and assistance in
                                                     CalPERS. Check with your agency Health
completing it.
                                                     Benefits Officer (or, if you are retired, the
                                                     CalPERS Office of Employer and Member
                                                     Health Services) if you have questions.




                                                                                                      11
HOW TO OBTAIN SERVICES

As a Member, you are selecting our medical care     applies when you obtain care in your Home
program to provide your health care. You must       Region.
receive all covered care from Plan Providers
inside your Home Region’s Service Area, except      Our medical care program gives you access to all
as described in the sections listed below for the   of the covered Services you may need, such as
following Services:                                 routine care with your own personal Plan
• Authorized referrals as described under           Physician, hospital care, laboratory and pharmacy
  “Getting a Referral” in this “How to Obtain       Services, Emergency Care, Urgent Care, and
  Services” section                                 other benefits described in the “Benefits,
                                                    Copayments, and Coinsurance” section.
• Durable medical equipment as described under
  “Durable Medical Equipment for Home Use”
                                                    Routine Care
  in the “Benefits, Copayments, and
  Coinsurance” section                              If you need to make a routine care appointment,
• Emergency ambulance Services as described         please refer to Your Guidebook to Kaiser
  under “Ambulance Services” in the “Benefits,      Permanente Services (Your Guidebook) for
  Copayments, and Coinsurance” section              appointment telephone numbers, or go to our
                                                    Web site at kp.org to request an appointment
• Emergency Care, Post-Stabilization Care, and      online. Routine appointments are for medical
  Out-of-Area Urgent Care as described in the       needs that aren’t urgent (such as routine
  “Emergency, Post-Stabilization, and Out-of-       preventive care and school physicals). Try to
  Area Urgent Care from Non–Plan Providers”         make your routine care appointments as far in
  section                                           advance as possible.
• Home health care as described under “Home
  Health Care” in the “Benefits, Copayments,        Urgent Care
  and Coinsurance” section
                                                    When you are sick or injured, you may have an
• Hospice care as described under “Hospice          Urgent Care need. An Urgent Care need is one
  Care” in the “Benefits, Copayments, and           that requires prompt medical attention but is not
  Coinsurance” section                              an Emergency Medical Condition. If you think
• Ostomy and urological supplies as described       you may need Urgent Care, call the appropriate
  under “Ostomy and Urological Supplies” in         appointment or advice nurse telephone number at
  the “Benefits, Copayments, and Coinsurance”       a Plan Facility. Please refer to Your Guidebook
  section                                           for advice nurse and Plan Facility telephone
                                                    numbers.
• Prosthetic and orthotic devices as described
  under “Prosthetic and Orthotic Devices” in the
                                                    For information about Out-of-Area Urgent Care,
  “Benefits, Copayments, and Coinsurance”
                                                    please refer to the “Emergency,
  section
                                                    Post-Stabilization, and Out-of-Area Urgent Care
                                                    from Non–Plan Providers” section.
As a Member, you are enrolled in one of two
Health Plan Regions in California (either our
Northern California Region or Southern              Our Advice Nurses
California Region), called your Home Region.        We know that sometimes it’s difficult to know
The coverage information in this DF/EOC             what type of care you need. That’s why we have
12
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


telephone advice nurses available to assist you.     at the phone number listed in Your Guidebook.
Our advice nurses are registered nurses (RNs)        You can change your personal Plan Physician for




                                                                                                            Part One − Basic Plan
specially trained to help assess medical             any reason.
symptoms and provide advice over the phone,
when medically appropriate. Whether you are          Getting a Referral
calling for advice or to make an appointment, you
                                                     Referrals to Plan Providers
can speak to an advice nurse. They can often
answer questions about a minor concern, tell you     A Plan Physician must refer you before you can
what to do if a Plan Medical Office is closed, or    receive care from specialists, such as specialists
advise you about what to do next, including          in surgery, orthopedics, cardiology, oncology,
making a same-day Urgent Care appointment for        urology, and dermatology. However, you do not
you if it’s medically appropriate. To reach an       need a referral to receive care from any of the
advice nurse, please refer to Your Guidebook for     following:
the telephone numbers.                               • Your personal Plan Physician
                                                     • Generalists in internal medicine, pediatrics,
Your Personal Plan Physician                           and family practice
Personal Plan Physicians provide primary care        • Specialists in optometry, psychiatry, chemical
and play an important role in coordinating care,       dependency, and obstetrics/gynecology
including hospital stays and referrals to
specialists.                                         Medical Group authorization procedure for
                                                     certain referrals
We encourage you to choose a personal Plan
                                                     The following Services require prior
Physician. You may choose any available
                                                     authorization by the Medical Group for the
personal Plan Physician. Most personal Plan
                                                     Services to be covered (prior authorization means
Physicians are Primary Care Physicians
                                                     that the Medical Group must approve the
(generalists in internal medicine, pediatrics, or
                                                     Services in advance for the Services to be
family practice, or specialists in
                                                     covered):
obstetrics/gynecology who the Medical Group
designates as Primary Care Physicians). Some         • Durable medical equipment (DME). If your
specialists who are not designated as Primary          Plan Physician prescribes a DME item, he or
Care Physicians but who also provide primary           she will submit a written referral to the Plan
care may be available as personal Plan                 Hospital’s DME coordinator, who will
Physicians. For example, some specialists in           authorize the DME item if he or she
internal medicine and obstetrics/gynecology who        determines that your DME coverage includes
are not designated as Primary Care Physicians          the item and that the item is listed on our
may be available as personal Plan Physicians.          formulary for your condition. If the item
                                                       doesn’t appear to meet our DME formulary
To learn how to select a personal Plan Physician,      guidelines, then the DME coordinator will
please refer to Your Guidebook or call our             contact the Plan Physician for additional
Member Service Call Center. You can find a             information. If the DME request still doesn’t
directory of our Plan Physicians on our Web site       appear to meet our DME formulary guidelines,
at kp.org. For the current list of physicians that     it will be submitted to the Medical Group’s
are available as Primary Care Physicians, please       designee Plan Physician, who will authorize
call the personal physician selection department       the item if he or she determines that it is
                                                       Medically Necessary. For more information

                                                                                                       13
     about our DME formulary, please refer to          from a Plan Provider. Referrals to Non–Plan
     “Durable Medical Equipment for Home Use”          Physicians will be for a specific treatment
     in the “Benefits, Copayments, and                 plan, which may include a standing referral if
     Coinsurance” section                              ongoing care is prescribed. Please ask your
• Home health care. If your Plan Physician             Plan Physician what Services have been
  makes a written referral for at least eight          authorized
  continuous hours of home health nursing or         • Transplants. If your Plan Physician makes a
  other care, the Medical Group’s designee Plan        written referral for a transplant, the Medical
  Physician or committee will authorize the            Group’s regional transplant advisory
  Services if the designee determines that they        committee or board (if one exists) will
  are Medically Necessary and that they are not        authorize the Services if it determines that they
  the types of Services that an unlicensed family      are Medically Necessary. In cases where no
  member or other layperson could provide              transplant committee or board exists, the
  safely and effectively in the home setting after     Medical Group will refer you to physician(s)
  receiving appropriate training                       at a transplant center, and the Medical Group
• Ostomy and urological supplies. If your Plan         will authorize the Services if the transplant
  Physician prescribes ostomy or urological            center’s physician(s) determine that they are
  supplies, he or she will submit a written            Medically Necessary. Note: A Plan Physician
  referral to the Plan Hospital’s designated           may provide or authorize a corneal transplant
  coordinator, who will authorize the item if he       without using this Medical Group transplant
  or she determines that it is covered and the         authorization procedure
  item is listed on our soft goods formulary for
  your condition. If the item doesn’t appear to      Decisions regarding requests for authorization
  meet our soft goods formulary guidelines, then     will be made only by licensed physicians or other
  the coordinator will contact the Plan Physician    appropriately licensed medical professionals.
  for additional information. If the request still
  doesn’t appear to meet our soft goods              Medical Group’s decision time frames. The
  formulary guidelines, it will be submitted to      applicable Medical Group designee will make the
  the Medical Group’s designee Plan Physician,       authorization decision within the time frame
  who will authorize the item if he or she           appropriate for your condition, but no later than
  determines that it is Medically Necessary. For     five business days after receiving all the
  more information about our soft goods              information (including additional examination
  formulary, please refer to “Ostomy and             and test results) reasonably necessary to make the
  Urological Supplies” in the “Benefits,             decision, except that decisions about urgent
  Copayments, and Coinsurance” section               Services will be made no later than 72 hours after
                                                     receipt of the information reasonably necessary to
• Services not available from Plan Providers.
                                                     make the decision. If the Medical Group needs
  If your Plan Physician decides that you require
                                                     more time to make the decision because it doesn’t
  covered Services not available from Plan
                                                     have information reasonably necessary to make
  Providers, he or she will recommend to the
                                                     the decision, or because it has requested
  Medical Group that you be referred to a Non–
                                                     consultation by a particular specialist, you and
  Plan Provider inside or outside your Home
                                                     your treating physician will be informed about
  Region’s Service Area. The appropriate
                                                     the additional information, testing, or specialist
  Medical Group designee will authorize the
                                                     that are needed, and the date that the Medical
  Services if he or she determines that they are
                                                     Group expects to make a decision.
  Medically Necessary and are not available

14
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Your treating physician will be informed of the       us becomes effective, you may be eligible for
decision within 24 hours after the decision is        limited coverage of that Non–Plan Provider’s




                                                                                                             Part One − Basic Plan
made. If the Services are authorized, your            Services.
physician will be informed of the scope of the
authorized Services. If the Medical Group does        Terminated provider. If you are currently
not authorize all of the Services, you will be sent   receiving covered Services in one of the cases
a written decision and explanation within two         listed below under “Eligibility” from a Plan
business days after the decision is made. The         Hospital or a Plan Physician (or certain other
letter will include information about your appeal     providers) when our contract with the provider
rights, which are described in the “Dispute           ends (for reasons other than medical disciplinary
Resolution” section. Any written criteria that the    cause or criminal activity), you may be eligible
Medical Group uses to make the decision to            for limited coverage of that terminated provider’s
authorize, modify, delay, or deny the request for     Services.
authorization will be made available to you upon
request.                                              Eligibility. The cases that are subject to this
                                                      completion of Services provision are:
Copayments and Coinsurance. The                       • Acute conditions, which are medical
Copayments and Coinsurance for these referral           conditions that involve a sudden onset of
Services are the Copayments and Coinsurance             symptoms due to an illness, injury, or other
required for Services provided by a Plan Provider       medical problem that requires prompt medical
as described in the “Benefits, Copayments, and          attention and has a limited duration. We may
Coinsurance” section.                                   cover these Services until the acute condition
                                                        ends
More information. This description is only a
brief summary of the authorization procedure.         • We may cover Services for serious chronic
                                                        conditions until the earlier of (1) 12 months
The policies and procedures (including a
                                                        from your effective date of coverage if you are
description of the authorization procedure or
                                                        a new Member, (2) 12 months from the
information about the authorization procedure
                                                        termination date of the terminated provider, or
applicable to some Plan Providers other than
                                                        (3) the first day after a course of treatment is
Kaiser Foundation Hospitals and the Medical
                                                        complete when it would be safe to transfer
Group) are available upon request from our
                                                        your care to a Plan Provider, as determined by
Member Service Call Center. Please refer to
                                                        Kaiser Permanente after consultation with the
“Post-Stabilization Care” in the “Emergency,
                                                        Member and Non–Plan Provider and
Post-Stabilization, and Out-of-Area Urgent Care
                                                        consistent with good professional practice.
from Non–Plan Providers” section for
                                                        Serious chronic conditions are illnesses or
authorization requirements that apply to Post-
                                                        other medical conditions that are serious, if
Stabilization Care from Non–Plan Providers.
                                                        one of the following is true about the
                                                        condition:
Completion of Services from Non–Plan
                                                        ♦ it persists without full cure
Providers
                                                        ♦ it worsens over an extended period of time
New Member. If you are currently receiving
Services from a Non–Plan Provider in one of the         ♦ it requires ongoing treatment to maintain
cases listed below under “Eligibility” and your            remission or prevent deterioration
prior plan’s coverage of the provider’s Services      • Pregnancy and immediate postpartum care.
has ended or will end when your coverage with           We may cover these Services for the duration

                                                                                                        15
     of the pregnancy and immediate postpartum       conditions pertaining to payment and to
     care                                            providing Services inside your Home Region’s
• Terminal illnesses, which are incurable or         Service Area
  irreversible illnesses that have a high          • The Services to be provided to you would be
  probability of causing death within a year or      covered Services under this DF/EOC if
  less. We may cover completion of these             provided by a Plan Provider
  Services for the duration of the illness         • You request completion of Services within 30
• Care for children under age 3. We may cover        days (or as soon as reasonably possible) from
  completion of these Services until the earlier     your effective date of coverage if you are a
  of (1) 12 months from the child’s effective        new Member or from the termination date of
  date of coverage if the child is a new Member,     the Plan Provider
  (2) 12 months from the termination date of the
  terminated provider, or (3) the child’s third    Copayments and Coinsurance. The
  birthday                                         Copayments and Coinsurance for completion of
• Surgery or another procedure that is             Services are the Copayments and Coinsurance
  documented as part of a course of treatment      required for Services provided by a Plan Provider
  and has been recommended and documented          as described in the “Benefits, Copayments, and
  by the provider to occur within 180 days of      Coinsurance” section.
  your effective date of coverage if you are a
  new Member or within 180 days of the             More information. For more information about
  termination date of the terminated provider      this provision, or to request the Services or a
                                                   copy of our “Completion of Covered Services”
To qualify for this completion of Services         policy, please call our Member Service Call
coverage, all of the following requirements must   Center.
be met:
                                                   Second Opinions
• Your Health Plan coverage is in effect on the
  date you receive the Service                     If you request a second opinion, it will be
• For new Members, your prior plan's coverage      provided to you when Medically Necessary by an
  of the provider's Services has ended or will     appropriately qualified medical professional. This
  end when your coverage with us becomes           is a physician who is acting within his or her
  effective                                        scope of practice and who possesses a clinical
                                                   background related to the illness or condition
• You are receiving Services in one of the cases   associated with the request for a second medical
  listed above from a Non–Plan Provider on         opinion.
  your effective date of coverage if you are a
  new Member, or from the terminated Plan          Here are some examples of when a second
  Provider on the provider’s termination date      opinion is Medically Necessary:
• For new Members, when you enrolled in            • Your Plan Physician has recommended a
  Health Plan, you did not have the option to        procedure and you are unsure about whether
  continue with your previous health plan or to      the procedure is reasonable or necessary
  choose another plan (including an out-of-
  network option) that would cover the Services    • You question a diagnosis or plan of care for a
  of your current Non–Plan Provider                  condition that threatens substantial impairment
                                                     or loss of life, limb, or bodily functions
• The provider agrees to our standard
  contractual terms and conditions, such as
16
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


• The clinical indications are not clear or are     Financial liability
  complex and confusing                             Our contracts with Plan Providers provide that




                                                                                                          Part One − Basic Plan
• A diagnosis is in doubt due to conflicting test   you are not liable for any amounts we owe.
  results                                           However, you may be liable for the cost of
                                                    noncovered Services you obtain from Plan
• The Plan Physician is unable to diagnose the
                                                    Providers or Non–Plan Providers.
  condition
• The treatment plan in progress is not             Termination of a Plan Provider’s contract
  improving your medical condition within an
                                                    If our contract with any Plan Provider terminates
  appropriate period of time, given the diagnosis
                                                    while you are under the care of that provider, we
  and plan of care
                                                    will retain financial responsibility for covered
• You have concerns about the diagnosis or plan     care you receive from that provider until we
  of care                                           make arrangements for the Services to be
                                                    provided by another Plan Provider and notify you
You can either ask your Plan Physician to help      of the arrangements. You may be eligible to
you arrange for a second medical opinion, or you    receive Services from a terminated provider;
can make an appointment with another Plan           please refer to “Completion of Services from
Physician. If the Medical Group determines that     Non–Plan Providers” under “Getting a Referral”
there isn’t a Plan Physician who is an              in this “How to Obtain Services” section.
appropriately qualified medical professional for
your condition, the Medical Group will authorize    Provider groups and hospitals. If you are
a referral to a Non–Plan Physician for a            assigned to a provider group or hospital whose
Medically Necessary second opinion.                 contract with us terminates, or if you live within
                                                    15 miles of a hospital whose contract with us
Copayments and Coinsurance. The                     terminates, we will give you written notice at
Copayments and Coinsurance for these referral       least 60 days before the termination (or as soon as
Services are the Copayments and Coinsurance         reasonably possible).
required for Services provided by a Plan Provider
as described in the “Benefits, Copayments, and      Visiting Other Regions
Coinsurance” section.
                                                    If you visit the service area of another Region
                                                    temporarily (not more than 90 days), you can
Contracts with Plan Providers
                                                    receive visiting member care from designated
How Plan Providers are paid                         providers in that area. Visiting member care is
Health Plan and Plan Providers are independent      described in our visiting member brochure.
contractors. Plan Providers are paid in a number    Visiting member care and your out-of-pocket
of ways, such as salary, capitation, per diem       costs may differ from the covered Services,
rates, case rates, fee for service, and incentive   Copayments, and Coinsurance described in this
payments. To learn more about how Plan              DF/EOC.
Physicians are paid to provide or arrange medical
and hospital care for Members, please ask your      The 90-day limit on visiting member care does
Plan Physician or call our Member Service Call      not apply to a Dependent child who attends an
Center.                                             accredited college or accredited vocational
                                                    school. The service areas and facilities where you



                                                                                                     17
may obtain visiting member care may change at         committed to your satisfaction and want to help
any time without notice                               you with your questions.

Please call our Member Service Call Center for        Member Services
more information about visiting member care,          Most Plan Facilities have an office staffed with
including facility locations in the service area of   representatives who can provide assistance if you
another Region, and to request a copy of the          need help obtaining Services. At different
visiting member brochure.                             locations, these offices may be called Member
                                                      Services, Patient Assistance, or Customer
Your Identification Card                              Service. In addition, our Member Service Call
Each Member’s Kaiser Permanente identification        Center representatives are available to assist you
card has a medical record number on it, which         weekdays from 7 a.m. to 7 p.m. and weekends
you will need when you call for advice, make an       from 7 a.m. to 3 p.m. (except holidays) toll free at
appointment, or go to a provider for covered care.    800-464-4000 or 800-777-1370 (TTY for the
When you get care, please bring your Kaiser           deaf, hard of hearing, or speech impaired). For
Permanente ID card and a photo ID. Your               your convenience, you can also contact us
medical record number is used to identify your        through our Web site at kp.org.
medical records and membership information.
Your medical record number should never               Member Services representatives at our Plan
change. Please call our Member Service Call           Facilities and Member Service Call Center can
Center if we ever inadvertently issue you more        answer any questions you have about your
than one medical record number, or if you need        benefits, available Services, and the facilities
to replace your Kaiser Permanente ID card.            where you can receive care. For example, they
                                                      can explain your Health Plan benefits, how to
Your ID card is for identification only. To receive   make your first medical appointment, what to do
covered Services, you must be a current Member.       if you move, what to do if you need care while
Anyone who is not a Member will be billed as a        you are traveling, and how to replace your ID
non-Member for any Services he or she receives.       card. These representatives can also help you if
If you let someone else use your ID card, we will     you need to file a claim as described in the
submit the matter to CalPERS for appropriate          “Requests for Payment or Services” section or
action as described under “Termination for            with any issues as described in the “Dispute
Cause” in the “Termination of Membership”             Resolution” section.
section.
                                                      Interpreter services
Getting Assistance                                    If you need interpreter services when you call us
                                                      or when you get covered Services, please let us
We want you to be satisfied with the health care
                                                      know. Interpreter services are available 24 hours
you receive from Kaiser Permanente. If you have
                                                      a day, seven days a week, at no cost to you. For
any questions or concerns, please discuss them
                                                      more information on the interpreter services we
with your personal Plan Physician or with other
                                                      offer, please call our Member Service Call
Plan Providers who are treating you. They are
                                                      Center.




18
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


EMERGENCY, POST-STABILIZATION, AND OUT-OF-AREA
URGENT CARE FROM NON–PLAN PROVIDERS




                                                                                                          Part One − Basic Plan
This “Emergency, Post-Stabilization, and Out-of-    Care from Non–Plan Providers. However, you
Area Urgent Care from Non–Plan Providers”           must get prior authorization from us for Post-
section explains how to obtain covered              Stabilization Care from Non–Plan Providers
Emergency Care, Post-Stabilization Care, and        (prior authorization means that we must approve
Out-of-Area Urgent Care from Non–Plan               the Services in advance for the Services to be
Providers. We do not cover the Non–Plan             covered).
Provider care discussed in this section unless it
meets both of the following requirements:           Emergency Care
• This “Emergency, Post-Stabilization, and Out-     If you have an Emergency Medical Condition,
  of-Area Urgent Care from Non–Plan                 call 911 or go to the nearest hospital. When you
  Providers” section says that we cover the care    have an Emergency Medical Condition, we cover
• The care would be covered under the               Emergency Care anywhere in the world.
  “Benefits, Copayments, and Coinsurance”
  section (subject to the “Exclusions,              An Emergency Medical Condition is: (1) a
  Limitations, Coordination of Benefits, and        medical or psychiatric condition that manifests
  Reductions” section) if you received the care     itself by acute symptoms of sufficient severity
  from a Plan Provider                              (including severe pain) such that you could
                                                    reasonably expect the absence of immediate
For example, we will not cover Non-Plan Skilled     medical attention to result in serious jeopardy to
Nursing Facility care as part of authorized Post-   your health or body functions or organs, or (2)
Stabilization Care unless both of the following     active labor when there isn't enough time for safe
are true:                                           transfer to a Plan Hospital (or designated
• This “Emergency, Post-Stabilization, and Out-     hospital) before delivery or if transfer poses a
  of-Area Urgent Care from Non–Plan                 threat to your (or your unborn child's) health and
  Providers” section says that we cover the care    safety.
  (we authorize the care and the care meets the
  definition of “Post-Stabilization Care”)          For ease and continuity of care, we encourage
                                                    you to go to a Plan Hospital Emergency
• The care would be covered under “Skilled          Department listed in Your Guidebook if you are
  Nursing Facility Care” in the “Benefits,          inside your Home Region’s Service Area, but
  Copayments, and Coinsurance” section              only if it is reasonable to do so, considering your
  (subject to the “Exclusions, Limitations,         condition or symptoms.
  Coordination of Benefits, and Reductions”
  section) if you received the care from a Plan     Post-Stabilization Care
  Skilled Nursing Facility inside your Home
  Region's Service Area                             Post-Stabilization Care is Medically Necessary
                                                    Services related to your Emergency Medical
Prior Authorization                                 Condition that you receive after your treating
                                                    physician determines that this condition is
You do not need to get prior authorization from     Clinically Stable. We cover Post-Stabilization
us to get Emergency Care or Out-of-Area Urgent      Care from a Non–Plan Provider, including


                                                                                                     19
inpatient care at a Non–Plan Hospital, only if we     Out-of-Area Urgent Care
provide prior authorization for the care.
                                                      If you have an Urgent Care need due to an
                                                      unforeseen illness, unforeseen injury, or
To request authorization to receive Post-
                                                      unforeseen complication of an existing condition
Stabilization Care from a Non–Plan Provider, you
                                                      (including pregnancy), we cover Medically
must call us toll free at 800-225-8883 (TTY users
                                                      Necessary Services to prevent serious
call 711) or the notification telephone number on
                                                      deterioration of your (or your unborn child’s)
your Kaiser Permanente ID card before you
                                                      health from a Non–Plan Provider if all of the
receive the care if it is reasonably possible to do
                                                      following are true:
so (otherwise, call us as soon as reasonably
possible). After we are notified, we will discuss     • You receive the Services from Non–Plan
your condition with the Non–Plan Provider. If we        Providers while you are temporarily outside
decide that you require Post-Stabilization Care         your Home Region’s Service Area
and that this care would be covered if you            • You reasonably believed that your (or your
received it from a Plan Provider, we will               unborn child’s) health would seriously
authorize your care from the Non–Plan Provider          deteriorate if you delayed treatment until you
or arrange to have a Plan Provider (or other            returned to your Home Region’s Service Area
designated provider) provide the care. If we
decide to have a Plan Hospital, Plan Skilled          Follow-up Care
Nursing Facility, or designated Non–Plan
Provider provide your care, we may authorize          We do not cover follow-up care provided by
special transportation services that are medically    Non–Plan Providers unless it is covered
required to get you to the provider. This may         Emergency Care, Post-stabilization Care, or
include transportation that is otherwise not          Out-of-Area Urgent Care described in this
covered.                                              “Emergency, Post-stabilization, and Out-of-Area
                                                      Urgent Care from Non–Plan Providers” section.
Be sure to ask the Non–Plan Provider to tell you
what care (including any transportation) we have      Payment and Reimbursement
authorized because we will not cover                  If you receive Emergency Care,
unauthorized Post-Stabilization Care or related       Post-Stabilization Care, or Out-of-Area Urgent
transportation provided by Non–Plan Providers.        Care from a Non–Plan Provider, you must pay
                                                      the provider and file a claim for reimbursement
We understand that extraordinary circumstances        unless the provider agrees to bill us. Also, you
can delay your ability to call us to request          may be required to pay and file a claim for any
authorization for Post-Stabilization Care from a      Services prescribed by a Non–Plan Provider in
Non–Plan Provider, for example, if a young child      conjunction with covered Emergency Care,
is without a parent or guardian present, or you are   Post-Stabilization Care, and Out-of-Area Urgent
unconscious. In these cases, you must call us as      Care even if you receive the Services from a Plan
soon as reasonably possible. Please keep in mind      Provider, such as a Plan Pharmacy.
that anyone can call us for you. We do not cover
any care you receive from Non–Plan Providers          To request payment or reimbursement, you must
after you’re Clinically Stable unless we authorize    file a claim as described under “Requests for
it, so if you don’t call as soon as reasonably        Payment” in the “Requests for Payment or
possible, you increase the risk that you will have    Services” section.
to pay for this care.


20
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Copayments and Coinsurance                        Copayments, and Coinsurance” section. We will
                                                  reduce any payment we make to you or the
The Copayments and Coinsurance for Emergency




                                                                                                   Part One − Basic Plan
                                                  Non–Plan Provider by applicable Copayments
Care, Post-Stabilization Care, or Out-of-Area
                                                  and Coinsurance.
Urgent Care are the Copayments and
Coinsurance required for Services provided by a
Plan Provider as described in the “Benefits,




                                                                                              21
BENEFITS, COPAYMENTS, AND COINSURANCE

We cover the Services described in this                    in the “Emergency, Post-Stabilization, and
“Benefits, Copayments, and Coinsurance”                    Out-of-Area Urgent Care from Non–Plan
section, subject to all provisions in the                  Providers” section
“Exclusions, Limitations, Coordination of              ♦   home health care as described under “Home
Benefits, and Reductions” section, only if all of          Health Care” in the “Benefits, Copayments,
the following conditions are satisfied:                    and Coinsurance” section
• You are a Member on the date that you receive        ♦   hospice care as described under “Hospice
  the Services                                             Care” in this “Benefits, Copayments, and
• The Services are Medically Necessary                     Coinsurance” section
                                                       ♦   ostomy and urological supplies as described
• The Services are provided, prescribed,
                                                           under “Ostomy and Urological Supplies” in
  authorized, or directed by a Plan Physician
                                                           the “Benefits, Copayments, and
  except where specifically noted to the contrary
                                                           Coinsurance” section
  in the sections listed below for the following
  Services:                                            ♦   prosthetic and orthotic devices as described
                                                           under “Prosthetic and Orthotic Devices” in
  ♦ emergency ambulance Services as described
                                                           the “Benefits, Copayments, and
     under “Ambulance Services” in this
                                                           Coinsurance” section
     “Benefits, Copayments, and Coinsurance”
     section
                                                    The only Services we cover under this DF/EOC
  ♦ emergency Care, Post-Stabilization Care,
                                                    are those that this “Benefits, Copayments, and
     and Out-of-Area Urgent Care as described       Coinsurance” section says that we cover, subject
     in the “Emergency, Post-Stabilization, and     to exclusions and limitations described in this
     Out-of-Area Urgent Care from Non–Plan
                                                    “Benefits, Copayments, and Coinsurance” section
     Providers” section
                                                    and to all provisions in the “Exclusions,
• You receive the Services from Plan Providers      Limitations, Coordination of Benefits, and
  inside your Home Region’s Service Area,           Reductions” section. The “Exclusions,
  except where specifically noted to the contrary   Limitations, Coordination of Benefits, and
  in the sections listed below for the following    Reductions” section describes exclusions,
  Services:                                         limitations, reductions, and coordination of
  ♦ authorized referrals as described under         benefits provisions that apply to all Services that
     “Getting a Referral” in the “How to Obtain     would otherwise be covered. When an exclusion
     Services” section                              or limitation applies only to a particular benefit, it
  ♦ durable medical equipment as described          is listed in the description of that benefit in this
     under “Durable Medical Equipment for           “Benefits, Copayments, and Coinsurance”
     Home Use” in the “Benefits, Copayments,        section. Also, please refer to:
     and Coinsurance” section                       • The “Emergency, Post-Stabilization, and
  ♦ emergency ambulance Services as described         Out-of-Area Urgent Care from Non–Plan
     under “Ambulance Services” in the                Providers” section for information about how
     “Benefits, Copayments, and Coinsurance”          to obtain covered Emergency Care,
     section                                          Post-Stabilization Care, and Out-of-Area
  ♦ Emergency Care, Post-Stabilization Care,
                                                      Urgent Care from Non–Plan Providers
     and Out-of-Area Urgent Care as described

22
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


• Your Guidebook for the types of covered               processes the order after receiving all the
  Services that are available from each Plan            information they need to fill the prescription




                                                                                                              Part One − Basic Plan
  Facility in your area, because some facilities      • Before starting or continuing a course of
  provide only specific types of covered                infertility Services, you may be required to pay
  Services                                              initial and subsequent deposits toward your
                                                        Copayment or Coinsurance for some or all of
Copayments and Coinsurance                              the entire course of Services, along with any
At the time you receive covered Services, you           past-due infertility-related Copayment or
must pay your Copayments and Coinsurance                Coinsurance. Any unused portion of your
amounts as described in this “Benefits,                 deposit will be returned to you. When a
Copayments, and Coinsurance” section. If you            deposit is not required, you must pay the
receive more than one Service from a provider, or       Copayment or Coinsurance for the procedure,
Services from more than one provider, you may           along with any past-due infertility-related
be required to pay separate Copayments or               Copayment or Coinsurance before you can
Coinsurance amounts for each Service and each           schedule an infertility procedure
provider. For example, if you receive Services
from two specialists in one visit, you may have to    Annual out-of-pocket maximum
pay the Copayments or Coinsurance for two             There is a limit to the total amount of
specialist visits. Similarly, if your physician       Copayments and Coinsurance you must pay
performs a procedure immediately after a              under this DF/EOC in a calendar year for all of
consultation, you may have to pay separate            the covered Services listed below that you receive
Copayments or Coinsurance amounts for the             in the same calendar year.
consultation visit and for the procedure. If you
have questions about Copayments and                   The limit is one of the following amounts:
Coinsurance, please contact our Member Service
                                                      • $1,500 per calendar year for self-only
Call Center.
                                                        enrollment (a Family of one Member)
In some cases, we may agree to bill you for your      • $1,500 per calendar year for any one Member
Copayments and Coinsurance amounts.                     in a Family of two or more Members
                                                      • $3,000 per calendar year for an entire Family
The Copayment or Coinsurance you must pay for           of two or more Members
each covered Service is described in this
“Benefits, Copayments, and Coinsurance”               If you are a Member in a Family of two or more
section. Copayments and Coinsurance are due at        Members, you reach the annual out-of-pocket
the time you receive the Services, except for the     maximum either when you meet the maximum
following:                                            for any one Member, or when your Family
• For items ordered in advance, you pay the           reaches the Family maximum. For example,
  Copayment or Coinsurance in effect on the           suppose you have reached the $1,500 maximum.
  order date (although we will not cover the item     For Services subject to the maximum, you will
  unless you still have coverage for it on the date   not pay any more Copayments or Coinsurance
  you receive it) and you may be required to pay      during the rest of the calendar year, but each
  the Copayment or Coinsurance before the item        other Member in your Family must continue to
  is ordered. For outpatient prescription drugs,      pay Copayments or Coinsurance during the
  the order date is the date that the pharmacy


                                                                                                         23
calendar year until your Family reaches the         Limitations, Coordination of Benefits, and
$3,000 maximum.                                     Reductions” section:
                                                    • Family planning visits
Payments that count toward the maximum.
The Copayments and Coinsurance you pay for          • Flexible sigmoidoscopies
the following Services apply toward the annual      • Health Education
out-of-pocket maximum except that Copayments        • Vaccines
and Coinsurance you pay for Services covered
under “Infertility Services” in this “Benefits,     • Mammograms
Copayments, and Coinsurance” section do not         • Routine preventive retinal photography
apply to the annual out-of-pocket maximum:            screenings
• Diabetic testing supplies and equipment and       • Routine preventive physical exams, including
  insulin-administration devices                      well-woman visits and eye refraction and
• Emergency Department visits                         hearing exams

• Office visits (including professional Services    • Scheduled prenatal visits and first postpartum
  such as dialysis treatment, health education,       visit
  and physical, occupational, and speech            • Tuberculosis tests
  therapy)                                          • Well-child preventive care visits
• Outpatient surgery                                  (0–23 months)
                                                    • The following laboratory tests:
Keeping track of the maximum. When you pay
                                                      ♦ cervical cancer screening, including
Copayment or Coinsurance amounts for a Service
                                                        screening for human papillomavirus (HPV)
that applies toward the annual out-of-pocket
maximum, ask for and keep the receipt. When the       ♦ cholesterol tests (lipid panel and profile)

receipts add up to the annual                         ♦ diabetes screening (fasting blood glucose
out-of-pocket maximum, please call our Member           tests)
Service Call Center to find out where to turn in      ♦ fecal occult blood tests
your receipts. When you turn them in, we will         ♦ HIV tests
give you a document stating that you don’t have
                                                      ♦ prostate specific antigen tests
to pay any more Copayments or Coinsurance for
Services subject to the annual out-of-pocket          ♦ STD tests
maximum through the end of the calendar year.
                                                    For preventive screening tests and vaccines that
Preventive Care Services                            Plan Physicians recommend for generally healthy
                                                    people, please refer to “Preventive Screenings
We cover a variety of preventive care Services,     and Vaccines” in the appendix to this DF/EOC.
which are Services to help keep you healthy or to   For more information about preventive care
prevent illness. This “Preventive Care Services”    guidelines, as well as recommended lifestyle
section lists examples of preventive care           practices, please refer to Your Guidebook to
Services, but it does not explain coverage. These   Kaiser Permanente Services, or visit our Web site
preventive care Services remain subject to the      at kp.org.
Copayments and Coinsurance and all other
coverage requirements described in this
“Benefits, Copayments, and Coinsurance” section
and all provisions in the “Exclusions,

24
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Outpatient Care                                       later cataract surgery. There is only one
                                                      Allowance of $150 after any cataract surgery.
We cover the following outpatient care for




                                                                                                          Part One − Basic Plan
preventive medicine, diagnosis, and treatment       • Up to two Medically Necessary contact lenses,
subject to the Copayment or Coinsurance               fitting, and dispensing per eye every 12
indicated:                                            months (including lenses we covered under
                                                      any other evidence of coverage offered by
• Routine preventive care:
                                                      your Group) to treat aniridia (missing iris):
  ♦ Physical exams, including
                                                      no charge
     well-woman visits: no charge
                                                    • Up to six Medically Necessary aphakic contact
  ♦ Well-child visits for Members through age
                                                      lenses, fitting, and dispensing per eye per
    23 months: no charge
                                                      calendar year (including lenses we covered
  ♦ Family planning visits for counseling, or to      under any other evidence of coverage offered
    obtain emergency contraceptive pills,             by your Group) to treat aphakia (absence of
    injectable contraceptives, internally             the crystalline lens of the eye) for Members
    implanted time-release contraceptives, or         through age 9: no charge
    intrauterine devices (IUDs):
    a $15 Copayment per visit                       • Outpatient surgery and other outpatient
                                                      procedures: a $15 Copayment per procedure
  ♦ After confirmation of pregnancy, the
    normal series of regularly scheduled            • Voluntary termination of pregnancy:
    preventive care prenatal visits and the first     a $15 Copayment per procedure
    postpartum visit: no charge                     • Physical, occupational, and speech therapy:
  ♦ Eye refraction exams to determine the need        a $15 Copayment per visit
    for vision correction and to provide a          • Physical, occupational, and speech therapy
    prescription for eyeglass lenses: no charge       provided in our organized, multidisciplinary
  ♦ Hearing tests to determine the need for           rehabilitation day-treatment program:
    hearing correction: no charge                     a $15 Copayment per day
  ♦ Vaccines (immunizations) administered to        • Urgent Care visits: a $15 Copayment
    you in a Plan Medical Office: no charge           per visit
• Primary and specialty care visits:                • Emergency Department visits:
  a $15 Copayment per visit                           a $50 Copayment per visit. This Copayment
• Allergy injection visits: no charge                 does not apply if you are admitted directly to
                                                      the hospital as an inpatient or if you are held
• Eyeglasses and contact lenses after each
                                                      for observation in a hospital unit outside the
  cataract surgery in accord with Medicare
                                                      Emergency Department
  guidelines: $150 Allowance. You can use the
  Allowance toward the purchase price of            • House calls by a Plan Physician (or a Plan
  eyeglass lenses, frames, and contact lenses         Provider who is a registered nurse) inside your
  (including fitting, and dispensing). The            Home Region’s Service Area when care can
  Allowance can be used only at the initial point     best be provided in your home as determined
  of sale. If you do not use all of your              by a Plan Physician: no charge
  Allowance at the initial point of sale, you       • Blood, blood products, and their
  cannot use it later. Also, the Allowance for        administration: no charge
  each cataract surgery must be used before a
                                                    • Administered drugs (drugs, injectables,
                                                      radioactive materials used for therapeutic

                                                                                                     25
     purposes, and allergy test and treatment        are generally and customarily provided by acute
     materials) prescribed in accord with our drug   care general hospitals inside your Home Region’s
     formulary guidelines, if administration or      Service Area:
     observation by medical personnel is required    • Room and board, including a private room
     and they are administered to you in a Plan        if Medically Necessary
     Medical Office or during home visits:
     no charge                                       • Specialized care and critical care units
• Some types of outpatient visits may be             • General and special nursing care
  available as group appointments, which are         • Operating and recovery rooms
  covered at a $7 Copayment per visit
                                                     • Services of Plan Physicians, including
                                                       consultation and treatment by specialists
The following types of outpatient Services are
covered only as described under these headings in    • Anesthesia
this “Benefits, Copayments, and Coinsurance”         • Drugs prescribed in accord with our drug
section:                                               formulary guidelines (for discharge drugs
• Chemical Dependency Services                         prescribed when you are released from the
                                                       hospital, please refer to “Outpatient
• Dental Services for Radiation Treatment and          Prescription Drugs, Supplies, and
  Dental Anesthesia                                    Supplements” in this “Benefits, Copayments,
• Dialysis Care                                        and Coinsurance” section)
• Durable Medical Equipment for Home Use             • Radioactive materials used for therapeutic
• Health Education                                     purposes

• Hearing Services                                   • Durable medical equipment and medical
                                                       supplies
• Home Health Care
                                                     • Imaging, laboratory, and special procedures
• Hospice Care
                                                     • Blood, blood products, and their
• Infertility Services                                 administration
• Mental Health Services                             • Obstetrical care and delivery (including
• Ostomy and Urological Supplies                       cesarean section). Note: If you are discharged
• Outpatient Imaging, Laboratory, and Special          within 48 hours after delivery (or within 96
  Procedures                                           hours if delivery is by cesarean section), your
                                                       Plan Physician may order a follow-up visit for
• Outpatient Prescription Drugs, Supplies, and         you and your newborn to take place within 48
  Supplements                                          hours after discharge
• Prosthetic and Orthotic Devices                    • Physical, occupational, and speech therapy
• Reconstructive Surgery                               (including treatment in our organized,
• Services Associated with Clinical Trials             multidisciplinary rehabilitation program)

• Transplant Services                                • Respiratory therapy
                                                     • Medical social services and discharge planning
Hospital Inpatient Care
                                                     The following types of inpatient Services are
We cover the following inpatient Services at
                                                     covered only as described under the following
no charge in a Plan Hospital, when the Services

26
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


headings in this “Benefits, Copayments, and            provide and that the use of other means of
Coinsurance” section:                                  transportation would endanger your health. These




                                                                                                              Part One − Basic Plan
• Chemical Dependency Services                         Services are covered only when the vehicle
                                                       transports you to or from covered Services.
• Dental Services for Radiation Treatment and
  Dental Anesthesia
                                                       Ambulance Services exclusion
• Dialysis Care
                                                       • Transportation by car, taxi, bus, gurney van,
• Hospice Care                                           wheelchair van, and any other type of
• Infertility Services                                   transportation (other than a licensed
                                                         ambulance or psychiatric transport van), even
• Mental Health Services
                                                         if it is the only way to travel to a Plan Provider
• Prosthetic and Orthotic Devices
• Reconstructive Surgery                               Chemical Dependency Services
• Services Associated with Clinical Trials             Inpatient detoxification
• Skilled Nursing Facility Care                        We cover hospitalization at no charge in a Plan
• Transplant Services                                  Hospital only for medical management of
                                                       withdrawal symptoms, including room and board,
                                                       Plan Physician Services, drugs, dependency
Ambulance Services
                                                       recovery Services, education, and counseling.
Emergency
When you have an Emergency Medical                     Outpatient chemical dependency care
Condition, we cover emergency Services of a            We cover the following Services for treatment of
licensed ambulance anywhere in the world at            chemical dependency:
no charge. In accord with the “Emergency,
                                                       • Day-treatment programs
Post-Stabilization, and Out-of-Area Urgent Care
from Non–Plan Providers” section, we cover             • Intensive outpatient programs
emergency ambulance Services that are not              • Individual and group chemical dependency
ordered by us only if one of the following is true:      counseling visits
• Your treating physician determines that you          • Visits for the purpose of medical treatment for
  must be transported to another facility when           withdrawal symptoms
  you are not Clinically Stable because the care
  you need is not available at the treating facility   You pay the following for these covered
• You are not already being treated, and you           Services:
  reasonably believe that your condition requires      • Individual visits: a $15 Copayment per visit
  ambulance transportation
                                                       • Group visits: a $5 Copayment per visit
Nonemergency
                                                       We cover methadone maintenance treatment at
Inside your Home Region’s Service Area, we             no charge for pregnant Members during
cover nonemergency ambulance and psychiatric           pregnancy and for two months after delivery at a
transport van Services at no charge if a Plan          licensed treatment center approved by the
Physician determines that your condition requires      Medical Group. We do not cover methadone
the use of Services that only a licensed
ambulance (or psychiatric transport van) can

                                                                                                        27
maintenance treatment in any other                   Dental anesthesia
circumstances.                                       For dental procedures at a Plan Facility, we
                                                     provide general anesthesia and the facility’s
Transitional residential recovery Services           Services associated with the anesthesia if all of
We cover chemical dependency treatment in a          the following are true:
nonmedical transitional residential recovery         • You are under age 7, or you are
setting approved in writing by the Medical             developmentally disabled, or your health is
Group. We cover these Services at no charge.           compromised
These settings provide counseling and support
services in a structured environment.                • Your clinical status or underlying medical
                                                       condition requires that the dental procedure be
                                                       provided in a hospital or outpatient surgery
Note: The following Services are not covered
                                                       center
under this “Chemical Dependency Services”
section:                                             • The dental procedure would not ordinarily
• Outpatient laboratory Services (instead, refer       require general anesthesia
  to the “Outpatient Imaging, Laboratory, and
  Special Procedures” in this “Benefits,             We do not cover any other Services related to the
  Copayments, and Coinsurance” section)              dental procedure, such as the dentist’s Services.
• Outpatient prescription drugs (instead, refer to   For covered dental anesthesia Services, you will
  the “Outpatient Prescription Drugs, Supplies,      pay the Copayments and Coinsurance that you
  and Supplements” in this “Benefits,                would pay for hospital inpatient care or
  Copayments, and Coinsurance” section)
                                                     outpatient surgery, depending on the setting.

Chemical dependency Services exclusion               Note: Outpatient prescription drugs are not
• Services in a specialized facility for             covered under this “Dental Services for Radiation
  alcoholism, drug abuse, or drug addiction          Treatment and Dental Anesthesia” section
  except as otherwise described in this              (instead, refer to the “Outpatient Prescription
  “Chemical Dependency Services” section             Drugs, Supplies, and Supplements” in this
                                                     “Benefits, Copayments, and Coinsurance”
Dental Services for Radiation Treatment              section).
and Dental Anesthesia
                                                     Dialysis Care
Dental Services for radiation treatment
We cover dental evaluation, X-rays, fluoride         We cover acute and chronic dialysis Services if
treatment, and extractions necessary to prepare      all of the following requirements are met:
your jaw for radiation therapy of cancer in your     • The Services are provided inside your Home
head or neck at a $15 Copayment per visit if a         Region’s Service Area
Plan Physician provides the Services or if the       • You satisfy all medical criteria developed by
Medical Group authorizes a referral to a dentist       the Medical Group and by the facility
(as described in “Medical Group authorization          providing the dialysis
procedure for certain referrals” under “Getting a
                                                     • A Plan Physician provides a written referral
Referral” in the “How to Obtain Services”
                                                       for care at the facility
section).



28
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


After the referral to a dialysis facility, we cover   replacement of covered DME, is covered at
equipment, training, and medical supplies             no charge.




                                                                                                           Part One − Basic Plan
required for home dialysis.
                                                      We decide whether to rent or purchase the
You pay the following for these covered Services      equipment, and we select the vendor. We will
related to dialysis:                                  repair or replace the equipment, unless the repair
• Inpatient dialysis care: no charge                  or replacement is due to loss or misuse. You must
                                                      return the equipment to us or pay us the fair
• One routine office visit per month with the         market price of the equipment when we are no
  multidisciplinary nephrology team: no charge        longer covering it.
• All other office visits: a $15 Copayment
  per visit                                           Durable medical equipment items for diabetes
• Hemodialysis treatment: no charge                   The following diabetes blood-testing supplies and
                                                      equipment and insulin-administration devices are
Note: The following Services are not covered          covered under this “Durable Medical Equipment
under this “Dialysis Care” section:                   for Home Use” section:
• Laboratory Services (instead, refer to the          • Blood glucose monitors and their supplies
  “Outpatient Imaging, Laboratory, and Special          (such as blood glucose monitor test strips,
  Procedures” in this “Benefits, Copayments,            lancets, and lancet devices)
  and Coinsurance” section)                           • Insulin pumps and supplies to operate the
• Outpatient prescription drugs (instead, refer to      pump
  the “Outpatient Prescription Drugs, Supplies,
  and Supplements” in this “Benefits,                 About our DME formulary
  Copayments, and Coinsurance” section)               Our DME formulary includes the list of DME
• Outpatient administered drugs (instead, refer       that has been approved by our DME Formulary
  to the “Outpatient Care” in this “Benefits,         Executive Committee for our Members. Our
  Copayments, and Coinsurance” section)               DME formulary was developed by a
                                                      multidisciplinary clinical and operational work
Durable Medical Equipment for Home                    group with review and input from Plan
Use                                                   Physicians and medical professionals with DME
                                                      expertise (for example: physical, respiratory, and
For Members who live inside California, we
                                                      enterostomal therapists and home health). A
cover durable medical equipment (DME) for use
                                                      multidisciplinary DME Formulary Executive
in your home (or another location used as your
                                                      Committee is responsible for reviewing and
home inside California) in accord with our DME
                                                      revising the DME formulary. Our DME
formulary guidelines. DME for home use is an
                                                      formulary is periodically updated to keep pace
item that is intended for repeated use, primarily
                                                      with changes in medical technology and clinical
and customarily used to serve a medical purpose,
                                                      practice. To find out whether a particular DME
generally not useful to a person who is not ill or
                                                      item is included in our DME formulary, please
injured, and appropriate for use in the home.
                                                      call our Member Service Call Center.
Coverage is limited to the standard item of
                                                      Our formulary guidelines allow you to obtain
equipment that adequately meets your medical
                                                      nonformulary DME items (those not listed on our
needs. Covered DME, including repair and
                                                      DME formulary for your condition) if they would

                                                                                                      29
otherwise be covered and the Medical Group          diabetes and asthma). We cover individual office
determines that they are Medically Necessary as     visits at a $15 Copayment per visit. We provide
described in “Medical Group authorization           all other covered Services at no charge. You can
procedure for certain referrals” under “Getting a   also participate in programs that we don’t cover,
Referral” in the “How to Obtain Services”           which may require that you pay a fee.
section.
                                                    For more information about our healthy living
Note: The following items are not covered under     programs, please contact your local Health
this “Durable Medical Equipment for Home Use”       Education Department or call our Member
section:                                            Service Call Center, or go to our Web site at
• Diabetes urine-testing supplies and other         kp.org. Your Guidebook also includes
  insulin-administration devices (instead, refer    information about our healthy living programs.
  to “Outpatient Prescription Drugs, Supplies,
  and Supplements” in this “Benefits,               Hearing Services
  Copayments, and Coinsurance” section)             We cover the following:
• DME related to the terminal illness for           • Hearing tests to determine the need for hearing
  Members who are receiving covered hospice           correction: no charge
  care (instead, refer to “Hospice Care” in this
                                                    • Hearing tests to determine the appropriate
  “Benefits, Copayments, and Coinsurance”
                                                      hearing aid: no charge
  section)
                                                    • A $1,000 Allowance toward the purchase
Durable medical equipment for home use                price of hearing aid(s) every 36 months when
exclusions                                            prescribed by a Plan Physician or by a Plan
                                                      Provider who is an audiologist. We will cover
• Comfort, convenience, or luxury equipment or        hearing aids for both ears only if both aids are
  features                                            required to provide significant improvement
• Exercise or hygiene equipment                       that is not obtainable with only one hearing
                                                      aid. We will not provide the Allowance if we
• Dental appliances
                                                      have provided an Allowance toward (or
• Nonmedical items, such as sauna baths or            otherwise covered) a hearing aid for that ear
  elevators                                           within the previous 36 months. Also, the
• Modifications to your home or car                   Allowance can only be used at the initial point
                                                      of sale. If you do not use all of your
• Devices for testing blood or other body
                                                      Allowance at the initial point of sale, you
  substances (except diabetes blood glucose
                                                      cannot use it later
  monitors and their supplies)
                                                    • Visits to verify that the hearing aid conforms
• Electronic monitors of the heart or lungs
                                                      to the prescription: no charge
  except infant apnea monitors
                                                    • Visits for fitting, counseling, adjustment,
Health Education                                      cleaning, and inspection after the warranty is
                                                      exhausted: no charge
We cover a variety of healthy living (health
education) programs to help you take an active      We select the provider or vendor that will furnish
role in protecting and improving your health,       the covered hearing aid. Coverage is limited to
including programs for tobacco cessation, stress    the types and models of hearing aids furnished by
management, and chronic conditions (such as         the provider or vendor.

30
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Note: The following Services are not covered         • The Services are provided inside California
under this “Hearing Services” section:




                                                                                                          Part One − Basic Plan
• Services related to the ear or hearing other       The Medical Group must authorize any home
  than those related to hearing aids described in    health nursing or other care of at least eight
  this section (instead, refer to the applicable     continuous hours, in accord with “Medical Group
  heading in this “Benefits, Copayments, and         authorization procedure for certain referrals”
  Coinsurance” section)                              under “Getting a Referral” in the “How to Obtain
                                                     Services” section (that authorization procedure
• Cochlear implants and osseointegrated
                                                     does not apply to home health nursing or other
  external hearing devices (instead, refer to the
                                                     care of less than eight continuous hours).
  “Prosthetic and Orthotic Devices” in this
  “Benefits, Copayments, and Coinsurance”
                                                     The following types of Services are covered in
  section)
                                                     the home only as described under these headings
                                                     in this “Benefits, Copayments, and Coinsurance”
Hearing Services exclusions
                                                     section:
• Internally implanted hearing aids                  • Dialysis Care
• Replacement parts and batteries, repair of         • Durable Medical Equipment for Home Use
  hearing aids, and replacement of lost or broken
  hearing aids (the manufacturer warranty may        • Ostomy and Urological Supplies
  cover some of these)                               • Outpatient Prescription Drugs, Supplies, and
                                                       Supplements
Home Health Care                                     • Prosthetic and Orthotic Devices
Home health care means Services provided in the
home by nurses, medical social workers, home         Home health care exclusions
health aides, and physical, occupational, and        • Care of a type that an unlicensed family
speech therapists.                                     member or other layperson could provide
                                                       safely and effectively in the home setting after
We cover home health care at no charge only            receiving appropriate training. This care is
if all of the following are true:                      excluded even if we would cover the care if it
• You are substantially confined to your home          were provided by a qualified medical
  (or a friend’s or relative’s home)                   professional in a hospital or a Skilled Nursing
                                                       Facility
• Your condition requires the Services of a
  nurse, physical therapist, or speech therapist     • Care in the home if the home is not a safe and
  (home health aide Services are not covered           effective treatment setting
  unless you are also getting covered home
  health care from a nurse, physical therapist, or   Hospice Care
  speech therapist that only a licensed provider
                                                     Hospice care is a specialized form of
  can provide)
                                                     interdisciplinary health care designed to provide
• A Plan Physician determines that it is feasible    palliative care and to alleviate the physical,
  to maintain effective supervision and control      emotional, and spiritual discomforts of a Member
  of your care in your home and that the             experiencing the last phases of life due to a
  Services can be safely and effectively provided    terminal illness. It also provides support to the
  in your home                                       primary caregiver and the Member’s family. A


                                                                                                     31
Member who chooses hospice care is choosing to        • Palliative drugs prescribed for pain control and
receive palliative care for pain and other              symptom management of the terminal illness
symptoms associated with the terminal illness,          for up to a 100-day supply in accord with our
but not to receive care to try to cure the terminal     drug formulary guidelines. You must obtain
illness. You may change your decision to receive        these drugs from Plan Pharmacies. Certain
hospice care benefits at any time.                      drugs are limited to a maximum 30-day supply
                                                        in any 30-day period (please call our Member
We cover the hospice Services listed below at           Service Call Center for the current list of these
no charge only if all of the following                  drugs)
requirements are met:                                 • Durable medical equipment
• A Plan Physician has diagnosed you with a           • Respite care when necessary to relieve your
  terminal illness and determines that your life        caregivers. Respite care is occasional short-
  expectancy is 12 months or less                       term inpatient care limited to no more than
• The Services are provided inside California           five consecutive days at a time
  but within 15 miles or 30 minutes from your         • Counseling and bereavement services
  Home Region’s Service Area (including a
  friend’s or relative’s home inside California       • Dietary counseling
  but within 15 miles or 30 minutes from your         • The following care during periods of crisis
  Home Region’s Service Area even if you live           when you need continuous care to achieve
  there temporarily)                                    palliation or management of acute medical
• The Services are provided by a licensed               symptoms:
  hospice agency that is a Plan Provider                ♦ nursing care on a continuous basis for as
                                                          much as 24 hours a day as necessary to
• The Services are necessary for the palliation
                                                          maintain you at home
  and management of your terminal illness and
  related conditions                                    ♦ short-term inpatient care required at a level
                                                          that cannot be provided at home
If all of the above requirements are met, we cover
the following hospice Services, which are             Infertility Services
available on a 24-hour basis if necessary for your    We cover the following Services related to
hospice care:                                         involuntary infertility at 50% Coinsurance:
• Plan Physician Services                             • Services for diagnosis and treatment of
• Skilled nursing care, including assessment,           involuntary infertility
  evaluation, and case management of nursing          • Artificial insemination
  needs, treatment for pain and symptom
  control, provision of emotional support to you      Note: Outpatient drugs, supplies, and
  and your family, and instruction to caregivers      supplements are not covered under this
• Physical, occupational, or speech therapy for       “Infertility Services” section (instead, refer to the
  purposes of symptom control or to enable you        “Outpatient Prescription Drugs, Supplies, and
  to maintain activities of daily living              Supplements” section in this “Benefits,
• Respiratory therapy                                 Copayments, and Coinsurance” section for drug
                                                      coverage, including the Copayment that applies
• Medical social services                             for infertility drugs, which is listed under
• Home health aide and homemaker services             “Copayments and Coinsurance for outpatient
                                                      drugs, supplies, and supplements” in the

32
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


“Outpatient drugs, supplies, and supplements not     professionals. We cover these Services at
covered by Medicare” section).                       no charge.




                                                                                                           Part One − Basic Plan
Infertility Services exclusions                      Intensive psychiatric treatment programs. We
                                                     cover at no charge the following intensive
• Services to reverse voluntary, surgically
                                                     psychiatric treatment programs in a Plan Facility:
  induced infertility
                                                     • Short-term hospital-based intensive outpatient
• Semen and eggs (and Services related to their
                                                       care (partial hospitalization)
  procurement and storage)
                                                     • Short-term multidisciplinary treatment in an
Mental Health Services                                 intensive outpatient psychiatric treatment
                                                       program
We cover mental health Services as specified in
                                                     • Short-term treatment in a crisis residential
this “Mental Health Services” section
                                                       program in licensed psychiatric treatment
                                                       facility with 24-hour a day monitoring by
Outpatient mental health Services
                                                       clinical staff for stabilization of an acute
We cover:                                              psychiatric crisis
• Individual and group visits for diagnostic         • Psychiatric observation for an acute
  evaluation and psychiatric treatment                 psychiatric crisis
• Psychological testing
• Visits for the purpose of monitoring drug          Note: Outpatient drugs, supplies, and
  therapy                                            supplements are not covered under this “Mental
                                                     Health Services” section (instead, refer to the
You pay the following for these covered              “Outpatient Prescription Drugs, Supplies, and
Services:                                            Supplements” section in this “Benefits,
                                                     Copayments, and Coinsurance” section).
• Individual visits: a $15 Copayment
  per visit
                                                     Ostomy and Urological Supplies
• Group visits: a $7 Copayment per visit
                                                     For Members who live in California, we cover
                                                     ostomy and urological supplies prescribed in
Note: Outpatient intensive psychiatric treatment
                                                     accord with our soft goods formulary guidelines
programs are not covered under this “Outpatient
                                                     at no charge. We select the vendor, and coverage
mental health Services” section (refer to
                                                     is limited to the standard supply that adequately
“Intensive psychiatric treatment programs” in this
                                                     meets your medical needs.
“Mental Health Services” section).
                                                     About our soft goods formulary
Inpatient psychiatric hospitalization and
intensive psychiatric treatment programs
                                                     Our soft goods formulary includes the list of
                                                     ostomy and urological supplies that have been
                                                     approved by our Soft Goods Formulary
Inpatient psychiatric hospitalization. We cover
                                                     Executive Committee for our Members. Our Soft
inpatient psychiatric hospitalization in a Plan
                                                     Goods Formulary Executive Committee is
Hospital. Coverage includes room and board,
                                                     responsible for reviewing and revising the soft
drugs, Services of Plan Physicians, and Services
                                                     goods formulary. Our soft goods formulary is
of other Plan Providers who are mental health


                                                                                                      33
periodically updated to keep pace with changes in   • Laboratory tests (including screening tests for
medical technology and clinical practice.             diabetes, cardiovascular disease, cervical
                                                      cancer, and HPV, and tests for specific genetic
To find out whether a particular ostomy or            disorders for which genetic counseling is
urological supply is included in our soft goods       available): no charge
formulary, please call our Member Service Call      • Routine preventive retinal photography
Center.                                               screenings: no charge

Our formulary guidelines allow you to obtain        • All other diagnostic procedures provided by
nonformulary ostomy and urological supplies           Plan Providers who are not physicians (such as
(those not listed on our soft goods formulary for     electrocardiograms and
your condition) if they would otherwise be            electroencephalograms): no charge except that
                                                      certain diagnostic procedures are covered at
covered and the Medical Group determines that
                                                      a $15 Copayment per procedure if they are
they are Medically Necessary as described in
                                                      provided in an outpatient or ambulatory
“Medical Group authorization procedure for
                                                      surgery center or in a hospital operating room,
certain referrals” under “Getting a Referral” in
                                                      or if they are provided in any setting and a
the “How to Obtain Services” section.
                                                      licensed staff member monitors your vital
                                                      signs as you regain sensation after receiving
Ostomy and urological supplies exclusion
                                                      drugs to reduce sensation or to minimize
• Comfort, convenience, or luxury equipment or        discomfort
  features                                          • Radiation therapy: no charge
                                                    • Ultraviolet light treatments: no charge
Outpatient Imaging, Laboratory, and
Special Procedures
                                                    Note: Services related to diagnosis and treatment
We cover the following Services at the              of infertility are not covered under this
Copayment or Coinsurance indicated only when        “Outpatient Imaging, Laboratory, and Special
prescribed as part of care covered under other      Procedures” section (instead, refer to the
parts of this “Benefits, Copayments, and            “Infertility Services” section).
Coinsurance” section:
• Diagnostic and therapeutic imaging, such as       Outpatient Prescription Drugs,
  X-rays, mammograms, and ultrasound:               Supplies, and Supplements
  no charge except that certain imaging             We cover outpatient drugs, supplies, and
  procedures are covered at a $15 Copayment         supplements specified in this “Outpatient
  per procedure if they are provided in an
                                                    Prescription Drugs, Supplies, and Supplements”
  outpatient or ambulatory surgery center or in a
                                                    section when prescribed as follows and obtained
  hospital operating room, or if they are
                                                    through a Plan Pharmacy or our mail-order
  provided in any setting and a licensed staff
                                                    service:
  member monitors your vital signs as you
  regain sensation after receiving drugs to         • Items prescribed by Plan Physicians in accord
  reduce sensation or to minimize discomfort.         with our drug formulary guidelines
• Magnetic resonance imaging (MRI), computed        • Items prescribed by the following Non–Plan
  tomography (CT), and positron emission              Providers unless a Plan Physician determines
  tomography (PET): no charge                         that the item is not Medically Necessary or the
                                                      drug is for a sexual dysfunction disorder:
• Nuclear medicine: no charge

34
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


  ♦   Dentists if the drug is for dental care         obtained from a Plan Pharmacy. Items available
  ♦   Non–Plan Physicians if the Medical Group        through our mail-order service are subject to




                                                                                                            Part One − Basic Plan
      authorizes a written referral to the Non–Plan   change at any time without notice.
      Physician (in accord with “Medical Group
      authorization procedure for certain             Outpatient drugs, supplies, and supplements
      referrals” under “Getting a Referral” in the    We cover the following outpatient drugs,
      “How to Obtain Services” section) and the       supplies, and supplements:
      drug, supply, or supplement is covered as
                                                      • Drugs for which a prescription is required by
      part of that referral
                                                        law. We also cover certain drugs that do not
  ♦   Non–Plan Physicians if the prescription was       require a prescription by law if they are listed
      obtained in conjunction with covered              on our drug formulary. Note: Certain
      Emergency Care, Post-Stabilization Care, or       tobacco-cessation drugs are covered only if
      Out-of-Area Urgent Care described in the          you participate in a behavioral intervention
      “Emergency, Post-Stabilization, and               program approved by the Medical Group
      Out-of-Area Urgent Care from Non–Plan
                                                      • Diaphragms, cervical caps, and oral
      Providers” section (if you fill the
                                                        contraceptives (including emergency
      prescription at a Plan Pharmacy, you may
                                                        contraceptive pills)
      have to pay Charges for the item and file a
      claim for reimbursement as described under      • Disposable needles and syringes needed for
      “Requests for Payment” in the “Requests           injecting covered drugs
      for Payment or Services” section)               • Inhaler spacers needed to inhale covered drugs

How to obtain covered items                           Copayments and Coinsurance for outpatient
You must obtain covered drugs, supplies, and          drugs, supplies, and supplements. The
supplements from a Plan Pharmacy or through           Copayments and Coinsurance for these items are
our mail-order service unless the item is covered     as follows:
Emergency Care, Post-Stabilization Care, or           • Generic items:
Out-of-Area Urgent Care described in the
                                                        ♦ a $5 Copayment for up to a 30-day supply,
“Emergency, Post-Stabilization, and Out-of-Area
                                                          a $10 Copayment for a 31- to 60-day
Urgent Care from Non–Plan Providers” section.
                                                          supply, or a $15 Copayment for a 61- to
                                                          100-day supply at a Plan Pharmacy
Please refer to Your Guidebook for the locations
of Plan Pharmacies in your area.                        ♦ a $5 Copayment for up to a 30-day supply
                                                          or a $10 Copayment for a 31- to 100-day
Refills. You may be able to order refills from a          supply through our mail-order service
Plan Pharmacy, our mail-order service, or               ♦ drugs prescribed for the treatment of
through our Web site at kp.org/rxrefill. A Plan           infertility: 50% Coinsurance for up to a
Pharmacy or Your Guidebook can give you more              100-day supply
information about obtaining refills, including the
options available to you for obtaining refills. For
example, a few Plan Pharmacies don’t dispense
refills and not all drugs can be mailed through our
mail-order service. Please check with your local
Plan Pharmacy if you have a question about
whether or not your prescription can be mailed or

                                                                                                       35
• Brand-name items and compounded products:          covered under this paragraph (instead, refer to the
  ♦ a $15 Copayment for up to a 30-day               “Outpatient drugs, supplies, and supplements”
    supply, a $30 Copayment for a 31- to 60-         paragraph).
    day supply, or a $45 Copayment for a 61-
    to 100-day supply at a Plan Pharmacy             Diabetes urine-testing supplies and
  ♦ a $15 Copayment for up to a 30-day supply        insulin-administration devices
    or a $30 Copayment for a 31- to 100-day          We cover ketone test strips and sugar or acetone
    supply through our mail-order service            test tablets or tapes for diabetes urine testing at
  ♦ drugs prescribed for the treatment of            no charge for up to a 100-day supply.
    infertility: 50% Coinsurance for up to a
    100-day supply                                   We cover the following insulin-administration
                                                     devices at a $5 Copayment for up to a 100-day
• Amino acid–modified products used to treat         supply: pen delivery devices, disposable needles
  congenital errors of amino acid metabolism         and syringes, and visual aids required to ensure
  (such as phenylketonuria) and elemental
                                                     proper dosage (except eyewear).
  dietary enteral formula when used as a primary
  therapy for regional enteritis: no charge for up
                                                     Note: Diabetes blood-testing equipment (and
  to a 30-day supply
                                                     their supplies) and insulin pumps (and their
• Emergency contraceptive pills: no charge           supplies) are not covered under this “Outpatient
• Hematopoietic agents for dialysis: no charge       Prescription Drugs, Supplies, and Supplements”
  for up to a 30-day supply                          section (instead, refer to the “Durable Medical
                                                     Equipment for Home Use” section).
• Continuity drugs (if this DF/EOC is amended
  to exclude a drug that we have been covering
                                                     Day supply limit
  and providing to you under this DF/EOC, we
  will continue to provide the drug if a             The prescribing physician or dentist determines
  prescription is required by law and a Plan         how much of a drug, supply, or supplement to
  Physician continues to prescribe the drug for      prescribe. For purposes of day supply coverage
  the same condition and for a use approved by       limits, Plan Physicians determine the amount of
  the FDA): 50% Coinsurance for up to a              an item that constitutes a Medically Necessary
  30-day supply in a 30-day period                   30-, 60-, or 100-day supply for you. Upon
                                                     payment of the Copayments and Coinsurance
Note: If Charges for the drug, supply, or            specified in this “Outpatient Prescription Drugs,
supplement are less than the Copayment, you will     Supplies, and Supplements” section, you will
pay the lesser amount.                               receive the supply prescribed up to the day
                                                     supply limit also specified in this section. The
Certain IV drugs, supplies, and supplements          day supply limit is either a 30-day supply in a 30-
                                                     day period or a 100-day supply in a 100-day
We cover certain self-administered IV drugs,
                                                     period. If you wish to receive more than the
fluids, additives, and nutrients that require
                                                     covered day supply limit, then you must pay
specific types of parenteral-infusion (such as an
                                                     Charges for any prescribed quantities that exceed
IV or intraspinal-infusion) at no charge for up to
                                                     the day supply limit. Note: We cover episodic
a 30-day supply and the supplies and equipment
                                                     drugs prescribed for the treatment of sexual
required for their administration at no charge.
                                                     dysfunction disorders up to a maximum of 8
                                                     doses in any 30-day period or up to 27 doses in
Note: Injectable drugs, insulin, and drugs for the
                                                     any 100-day period.
diagnosis and treatment of infertility are not

36
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


The pharmacy may reduce the day supply               Note: The following Services are not covered
dispensed at the Copayment or Coinsurance            under this “Outpatient Prescription Drugs,




                                                                                                           Part One − Basic Plan
specified in this “Outpatient Prescription Drugs,    Supplies, and Supplements” section:
Supplies, and Supplements” section to a 30-day       • Durable medical equipment used to administer
supply in any 30-day period if the pharmacy            drugs (instead, refer to “Durable Medical
determines that the item is in limited supply in       Equipment for Home Use” in this “Benefits,
the market or for specific drugs (your Plan            Copayments, and Coinsurance” section)
Pharmacy can tell you if a drug you take is one of
these drugs).                                        • Outpatient administered drugs (instead, refer
                                                       to “Outpatient Care” in this “Benefits,
                                                       Copayments, and Coinsurance” section)
About our drug formulary
Our drug formulary includes the list of drugs that   • Drugs covered during a covered stay in a Plan
have been approved by our Pharmacy and                 Hospital or Skilled Nursing Facility (instead,
Therapeutics Committee for our Members. Our            refer to “Hospital Inpatient Care” and “Skilled
Pharmacy and Therapeutics Committee, which is          Nursing Facility Care” in this “Benefits,
primarily composed of Plan Physicians, selects         Copayments, and Coinsurance” section)
drugs for the drug formulary based on a number       • Drugs prescribed for pain control and
of factors, including safety and effectiveness as      symptom management of the terminal illness
determined from a review of medical literature.        for Members who are receiving covered
The Pharmacy and Therapeutics Committee                hospice care (instead, refer to “Hospice Care”
meets quarterly to consider additions and              in this “Benefits, Copayments, and
deletions based on new information or drugs that       Coinsurance” section)
become available.
                                                     Outpatient prescription drugs, supplies, and
If you would like to request a copy of our drug      supplements exclusions
formulary, please call our Member Service Call
Center. Note: The presence of a drug on our drug     • Any requested packaging (such as dose
                                                       packaging) other than the dispensing
formulary does not necessarily mean that your
                                                       pharmacy’s standard packaging
Plan Physician will prescribe it for a particular
medical condition.                                   • Compounded products unless the drug is listed
                                                       on our drug formulary or one of the
Our drug formulary guidelines allow you to             ingredients requires a prescription by law
obtain nonformulary prescription drugs (those not    • Drugs when prescribed to shorten the duration
listed on our drug formulary for your condition)       of the common cold
if they would otherwise be covered and a Plan
Physician determines that they are Medically         Prosthetic and Orthotic Devices
Necessary. If you disagree with your Plan
Physician’s determination that a nonformulary        For Members who live inside California, we
prescription drug is not Medically Necessary, you    cover the devices specified in this “Prosthetic and
may file a grievance as described in the “Dispute    Orthotic Devices” section if they are in general
Resolution” section. Also, our formulary             use, intended for repeated use, primarily and
guidelines may require you to participate in a       customarily used for medical purposes, and
behavioral intervention program approved by the      generally not useful to a person who is not ill or
Medical Group for specific conditions and you        injured. Coverage is limited to the standard
may be required to pay for the program.              device that adequately meets your medical needs.


                                                                                                     37
We select the provider or vendor that will furnish    • Other covered prosthetic and orthotic devices:
the covered device. Coverage includes fitting and       ♦ prosthetic devices required to replace all or
adjustment of these devices, their repair or              part of an organ or extremity, but only
replacement (unless due to loss or misuse), and           if they also replace the function of the organ
Services to determine whether you need a                  or extremity
prosthetic or orthotic device. If we do not cover       ♦ rigid and semi-rigid orthotic devices
the device, we will try to help you find facilities       required to support or correct a defective
where you may obtain what you need at a                   body part
reasonable price.
                                                        ♦ special footwear when custom made for
                                                          foot disfigurement due to disease, injury, or
Internally implanted devices
                                                          developmental disability
We cover at no charge internal devices
implanted during covered surgery, such as             Note: The following Services are not covered
pacemakers, intraocular lenses, cochlear              under this “Prosthetic and Orthotic Devices”
implants, osseointegrated external hearing            section:
devices, and hip joints.
                                                      • Eyeglasses and contact lenses following
External devices                                        cataract surgery (instead, refer to the
                                                        “Outpatient Care” section).
We cover the following external prosthetic and
orthotic devices, including repair and                • Hearing aids other than internally implanted
replacement of covered devices, at no charge:           devices described in this section (instead, refer
                                                        to “Hearing Services” in this “Benefits,
• Prosthetic devices and installation accessories
                                                        Copayments, and Coinsurance” section)
  to restore a method of speaking following the
  removal of all or part of the larynx (this
                                                      Prosthetic and orthotic devices exclusions
  coverage does not include electronic voice-
  producing machines, which are not prosthetic        • Dental appliances
  devices)                                            • Multifocal intraocular lenses and intraocular
• Prostheses needed after a Medically Necessary         lenses to correct astigmatism
  mastectomy, including custom-made                   • Except as otherwise described above in this
  prostheses when Medically Necessary and up            “Prosthetic and Orthotic Devices” section,
  to three brassieres required to hold a prosthesis     nonrigid supplies, such as elastic stockings and
  every 12 months                                       wigs
• Podiatric devices (including footwear) to           • Comfort, convenience, or luxury equipment or
  prevent or treat diabetes-related complications       features
  when prescribed by a Plan Physician or by a
  Plan Provider who is a podiatrist                   • Shoes or arch supports, even if custom-made,
                                                        except footwear described above in this
• Compression burn garments and lymphedema              “Prosthetic and Orthotic Devices” section for
  wraps and garments                                    diabetes-related complications and foot
• Enteral formula for Members who require tube          disfigurement
  feeding in accord with Medicare guidelines
• Prostheses to replace all or part of an external    Reconstructive Surgery
  facial body part that has been removed or           We cover reconstructive surgery to correct or
  impaired as a result of disease, injury, or         repair abnormal structures of the body caused by
  congenital defect
38
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


congenital defects, developmental abnormalities,      Reconstructive surgery exclusions
trauma, infection, tumors, or disease, if a Plan
                                                      • Surgery that, in the judgment of a Plan




                                                                                                               Part One − Basic Plan
Physician determines that it is necessary to
                                                        Physician specializing in reconstructive
improve function, or create a normal appearance,
                                                        surgery, offers only a minimal improvement in
to the extent possible.
                                                        appearance
Also, following Medically Necessary removal of        • Surgery that is performed to alter or reshape
all or part of a breast, we cover reconstruction of     normal structures of the body in order to
the breast, surgery and reconstruction of the other     improve appearance
breast to produce a symmetrical appearance, and
treatment of physical complications, including        Services Associated with Clinical Trials
lymphedemas.                                          We cover Services associated with cancer clinical
                                                      trials if all of the following requirements are met:
You pay the following for covered reconstructive
surgery Services:                                     • You are diagnosed with cancer

• Office visits: a $15 Copayment per visit            • You are accepted into a phase I, II, III, or IV
                                                        clinical trial for cancer
• Outpatient surgery: a $15 Copayment
  per procedure                                       • Your treating Plan Physician, or your treating
                                                        Non–Plan Physician if the Medical Group
• Hospital inpatient care (including room and           authorizes a written referral to the Non–Plan
  board, drugs, and Plan Physician Services):           Physician for treatment of cancer (in accord
  no charge                                             with “Medical Group authorization procedure
                                                        for certain referrals” under “Getting a
Note: The following Services are not covered            Referral” in the “How to Obtain Services”
under this “Reconstructive Surgery” section:            section), recommends participation in the
• Outpatient laboratory and imaging Services            clinical trial after determining that it has a
  (instead, refer to the “Outpatient Imaging,           meaningful potential to benefit you
  Laboratory, and Special Procedures” section in      • The Services would be covered under this
  this “Benefits, Copayments, and Coinsurance”          DF/EOC if they were not provided in
  section)                                              connection with a clinical trial
• Outpatient prescription drugs (instead, refer to    • The clinical trial has a therapeutic intent, and
  the “Outpatient Prescription Drugs, Supplies,         its end points are not defined exclusively to
  and Supplements” section in this “Benefits,           test toxicity
  Copayments, and Coinsurance” section)
                                                      • The clinical trial involves a drug that is exempt
• Outpatient administered drugs (instead, refer         under federal regulations from a new drug
  to the “Outpatient Care” in this “Benefits,           application, or the clinical trial is approved by:
  Copayments, and Coinsurance” section)                 one of the National Institutes of Health, the
• Prosthetics and orthotics (instead, refer to the      federal Food and Drug Administration (in the
  “Prosthetic and Orthotic Devices” section in          form of an investigational new drug
  this “Benefits, Copayments, and Coinsurance”          application), the U.S. Department of Defense,
  section)                                              or the U.S. Department of Veterans Affairs

                                                      For covered Services related to a clinical trial,
                                                      you will pay the Copayments and Coinsurance

                                                                                                          39
you would pay if the Services were not related         • Durable medical equipment in accord with our
to a clinical trial.                                     DME formulary if Skilled Nursing Facilities
                                                         ordinarily furnish the equipment
Services associated with clinical trials exclusions    • Imaging and laboratory Services that Skilled
• Services that are provided solely to satisfy data      Nursing Facilities ordinarily provide
  collection and analysis needs and are not used       • Medical social services
  in your clinical management
                                                       • Blood, blood products, and their
• Services that are customarily provided by the          administration
  research sponsors free of charge to enrollees in
                                                       • Medical supplies
  the clinical trial
                                                       • Physical, occupational, and speech therapy
Skilled Nursing Facility Care                          • Respiratory therapy
Inside your Home Region’s Service Area, we
cover at no charge up to 100 days per benefit          Note: Outpatient imaging, laboratory, and special
period (including any days we covered under any        procedures are not covered under this section
other evidence of coverage offered by your             (instead, refer to the “Outpatient Imaging,
Group) of skilled inpatient Services in a Plan         Laboratory, and Special Procedures” section in
Skilled Nursing Facility. The skilled inpatient        this “Benefits, Copayments, and Coinsurance”
Services must be customarily provided by a             section).
Skilled Nursing Facility, and above the level of
custodial or intermediate care.                        Transplant Services
                                                       We cover transplants of organs, tissue, or bone
A benefit period begins on the date you are            marrow if the Medical Group provides a written
admitted to a hospital or Skilled Nursing Facility     referral for care to a transplant facility as
at a skilled level of care. A benefit period ends on   described in “Medical Group authorization
the date you have not been an inpatient in a           procedure for certain referrals” under “Getting a
hospital or Skilled Nursing Facility, receiving a      Referral” in the “How to Obtain Services”
skilled level of care, for 60 consecutive days.        section.
A new benefit period can begin only after any
existing benefit period ends. A prior three-day        After the referral to a transplant facility, the
stay in an acute care hospital is not required.        following applies:
                                                       • If either the Medical Group or the referral
We cover the following Services:
                                                         facility determines that you do not satisfy its
• Physician and nursing Services                         respective criteria for a transplant, we will
• Room and board                                         only cover Services you receive before that
                                                         determination is made
• Drugs prescribed by a Plan Physician as part
  of your plan of care in the Plan Skilled             • Health Plan, Plan Hospitals, the Medical
  Nursing Facility in accord with our drug               Group, and Plan Physicians are not responsible
  formulary guidelines if they are administered          for finding, furnishing, or ensuring the
  to you in the Plan Skilled Nursing Facility by         availability of an organ, tissue, or bone
  medical personnel                                      marrow donor
                                                       • In accord with our guidelines for Services for
                                                         living transplant donors, we provide certain
                                                         donation-related Services for a donor, or an
40
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


  individual identified by the Medical Group as       Note: The following Services are not covered
  a potential donor, whether or not the donor is a    under this “Transplant Services” section:
  Member. These Services must be directly




                                                                                                           Part One − Basic Plan
                                                      • Outpatient laboratory and imaging Services
  related to a covered transplant for you, which        (instead, refer to the “Outpatient Imaging,
  may include certain Services for harvesting the       Laboratory, and Special Procedures” section in
  organ, tissue, or bone marrow and for                 this “Benefits, Copayments, and Coinsurance”
  treatment of complications. Our guidelines for        section)
  donor Services are available by calling our
  Member Service Call Center                          • Outpatient prescription drugs (instead, refer to
                                                        the “Outpatient Prescription Drugs, Supplies,
For covered transplant Services that you receive,       and Supplements” section in this “Benefits,
you will pay the Copayments and Coinsurance             Copayments, and Coinsurance” section)
you would pay if the Services were not related        • Outpatient administered drugs (instead, refer
to a transplant.                                        to the “Outpatient Care” section in this
                                                        “Benefits, Copayments, and Coinsurance”
We provide or pay for donation-related Services         section)
for actual or potential donors (whether or not they
are Members) in accord with our guidelines for
donor Services at no charge.




                                                                                                      41
EXCLUSIONS, LIMITATIONS, COORDINATION OF BENEFITS,
AND REDUCTIONS

Exclusions                                             impaired as a result of disease, injury, or
                                                       congenital defect.
The Services listed in this “Exclusions” section
are excluded from coverage. These exclusions
                                                       Custodial care
apply to all Services that would otherwise be
covered under this DF/EOC. Additional                  Custodial care means assistance with activities of
exclusions that apply only to a particular benefit     daily living (for example: walking, getting in and
are listed in the description of that benefit in the   out of bed, bathing, dressing, feeding, toileting,
“Benefits, Copayments, and Coinsurance”                and taking medicine), or care that can be
section.                                               performed safely and effectively by people who,
                                                       in order to provide the care, do not require
Certain exams and Services                             medical licenses or certificates or the presence of
                                                       a supervising licensed nurse.
Physical examinations and other Services
(1) required for obtaining or maintaining
                                                       This exclusion does not apply to Services covered
employment or participation in employee
                                                       under “Hospice Care” in the “Benefits,
programs, (2) required for insurance or licensing,
                                                       Copayments, and Coinsurance” section.
or (3) on court order or required for parole or
probation. This exclusion does not apply if a Plan
                                                       Dental care
Physician determines that the Services are
Medically Necessary.                                   Dental care and dental X-rays, such as dental
                                                       Services following accidental injury to teeth,
Conception by artificial means                         dental appliances, dental implants, orthodontia,
                                                       and dental Services resulting from medical
Except for artificial insemination covered under
                                                       treatment such as surgery on the jawbone and
“Infertility Services” in the “Benefits,
                                                       radiation treatment, except for Services covered
Copayments, and Coinsurance” section, all other
                                                       under “Dental Services for Radiation Treatment
Services related to conception by artificial means,
                                                       and Dental Anesthesia” in the “Benefits,
such as ovum transplants, gamete intrafallopian
                                                       Copayments, and Coinsurance” section.
transfer (GIFT), semen and eggs (and Services
related to their procurement and storage), in vitro
                                                       Disposable supplies
fertilization (IVF), and zygote intrafallopian
transfer (ZIFT).                                       Disposable supplies for home use, such as
                                                       bandages, gauze, tape, antiseptics, dressings,
Cosmetic Services                                      Ace-type bandages, and diapers, underpads, and
                                                       other incontinence supplies.
Services that are intended primarily to change or
maintain your appearance, except for Services
                                                       This exclusion does not apply to disposable
covered under “Reconstructive Surgery” and the
                                                       supplies covered under “Durable Medical
following prosthetic devices covered under
                                                       Equipment for Home Use,” “Home Health Care,”
“Prosthetic and Orthotic Devices” in the
                                                       “Hospice Care,” “Ostomy and Urological
“Benefits, Copayments, and Coinsurance”
                                                       Supplies,” and “Outpatient Prescription Drugs,
section: prostheses needed after a mastectomy,
                                                       Supplies, and Supplements” in the “Benefits,
and prostheses to replace all or part of an external
                                                       Copayments, and Coinsurance” section.
facial body part that has been removed or

42
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Experimental or investigational Services             • Contact lenses, including fitting and
A Service is experimental or investigational if        dispensing




                                                                                                           Part One − Basic Plan
we, in consultation with the Medical Group,          • Eye examinations for the purpose of obtaining
determine that one of the following is true:           or maintaining contact lenses
• Generally accepted medical standards do not        • Low vision devices
  recognize it as safe and effective for treating
  the condition in question (even if it has been     This exclusion does not apply to contact lenses to
  authorized by law for use in testing or other      treat aniridia, contact lenses to treat aphakia, or
  studies on human patients)                         eyewear following cataract surgery covered under
• It requires government approval that has not       “Outpatient Care” in the “Benefits, Copayments,
  been obtained when the Service is to be            and Coinsurance” section.
  provided
                                                     Hair loss or growth treatment
This exclusion does not apply to any of the          Services for the promotion, prevention, or other
following.                                           treatment of hair loss or hair growth.
• Experimental or investigational Services when
  an investigational application has been filed      Intermediate care
  with the federal Food and Drug Administration      Care in a licensed intermediate care facility. This
  (FDA) and the manufacturer or other source         exclusion does not apply to Services covered
  makes the Services available to you or Kaiser      under “Hospice Care” in the “Benefits,
  Permanente through an FDA-authorized               Copayments, and Coinsurance” section.
  procedure, except that we do not cover
  Services that are customarily provided by          Oral nutrition
  research sponsors free of charge to enrollees in
                                                     Outpatient oral nutrition, such as dietary
  a clinical trial or other investigational
                                                     supplements, herbal supplements, weight loss
  treatment protocol
                                                     aids, formulas, and food.
• Services covered under “Services Associated        This exclusion does not apply to any of the
  with Clinical Trials” in the “Benefits,            following:
  Copayments, and Coinsurance” section
                                                     • Amino acid–modified products and elemental
                                                       dietary enteral formula covered under
Please refer to the “Dispute Resolution” section       “Outpatient Prescription Drugs, Supplies, and
for information about Independent Medical              Supplements” in the “Benefits, Copayments,
Review related to denied requests for                  and Coinsurance” section
experimental or investigational Services.
                                                     • Enteral formula covered under “Prosthetic and
Eye surgery, eyeglasses and contact lenses, and        Orthotic Devices” in the “Benefits,
                                                       Copayments, and Coinsurance” section
contact lens eye examinations
• Services related to eye surgery or                 Routine foot care Services
  orthokeratologic Services for the purpose of
                                                     Routine foot care Services that are not Medically
  correcting refractive defects such as myopia,
                                                     Necessary.
  hyperopia, or astigmatism
• Eyeglass lenses and frames


                                                                                                      43
Services not approved by the FDA                     language development unless Medically
Drugs, supplements, tests, vaccines, devices,        Necessary.
radioactive materials, and any other Services that
by law require federal Food and Drug                 Surrogacy
Administration (FDA) approval in order to be         Services for anyone in connection with a
sold in the U.S., but are not approved by the        surrogacy arrangement, except for otherwise-
FDA. This exclusion applies to Services provided     covered Services provided to a Member who is a
anywhere, even outside the U.S.                      surrogate. A surrogacy arrangement is one in
                                                     which a woman (the surrogate) agrees to become
This exclusion does not apply to any of the          pregnant and to surrender the baby to another
following:                                           person or persons who intend to raise the child.
• Services covered under the “Emergency,             Please refer to “Surrogacy arrangements” under
  Post-Stabilization, and Out-of-Area Urgent         “Reductions” in this “Exclusions, Limitations,
  Care from Non-Plan Providers” section that         Coordination of Benefits, and Reductions”
  you receive outside the U.S.                       section for information about your obligations to
                                                     us in connection with a surrogacy arrangement,
• Experimental or investigational Services when      including your obligation to reimburse us for any
  an investigational application has been filed      Services we cover.
  with the FDA and the manufacturer or other
  source makes the Services available to you or
                                                     Transgender surgery
  Kaiser Permanente through an
  FDA-authorized procedure, except that we do
  not cover Services that are customarily            Travel and lodging expenses
  provided by research sponsors free of charge       Travel and lodging expenses, except that in some
  to enrollees in a clinical trial or other          situations if the Medical Group refers you to a
  investigational treatment protocol                 Non–Plan Provider as described in “Medical
                                                     Group authorization procedure for certain
• Services covered under “Services Associated
                                                     referrals” under “Getting a Referral” in the “How
  with Clinical Trials” in the “Benefits,
                                                     to Obtain Services” section, we may pay certain
  Copayments, and Coinsurance” section
                                                     expenses that we preauthorize in accord with our
                                                     travel and lodging guidelines. Our travel and
Please refer to the “Dispute Resolution” section
                                                     lodging guidelines are available from our
for information about Independent Medical
                                                     Member Service Call Center.
Review related to denied requests for
experimental or investigational Services.
                                                     Limitations
Services related to a noncovered Service             We will do our best to provide or arrange for our
When a Service is not covered, all Services          Members’ health care needs in the event of
related to the noncovered Service are excluded,      unusual circumstances that delay or render
except for Services we would otherwise cover to      impractical the provision of Services under this
treat complications of the noncovered Service.       DF/EOC, such as major disaster, epidemic, war,
                                                     riot, civil insurrection, disability of a large share
Speech therapy                                       of personnel at a Plan Facility, complete or partial
Speech therapy Services to treat social,             destruction of facilities, and labor disputes. Under
behavioral, or cognitive delays in speech or         these extreme circumstances, if you have an
                                                     Emergency Medical Condition, go to the nearest
                                                     hospital as described under “Emergency Care” in

44
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


the “Emergency, Post-Stabilization, and               If you have any questions about COB, please call
Out-of-Area Urgent Care from Non–Plan                 our Member Service Call Center.




                                                                                                            Part One − Basic Plan
Providers” section, and we will provide coverage
and reimbursement as described in that section.       Reductions
                                                      Employer responsibility
Additional limitations that apply only to a
particular benefit are listed in the description of   For any Services that the law requires an
that benefit in the “Benefits, Copayments, and        employer to provide, we will not pay the
Coinsurance” section.                                 employer, and when we cover any such Services
                                                      we may recover the value of the Services from
Coordination of Benefits (COB)                        the employer.

The Services covered under this DF/EOC are            Government agency responsibility
subject to coordination of benefits (COB) rules. If
                                                      For any Services that the law requires be
you have medical or dental coverage with another
                                                      provided only by or received only from a
health plan or insurance company, we will
                                                      government agency, we will not pay the
coordinate benefits with the other coverage under
                                                      government agency, and when we cover any such
the COB rules of the California Department of
                                                      Services we may recover the value of the
Managed Health Care. Those rules are
                                                      Services from the government agency.
incorporated into this DF/EOC.
                                                      Injuries or illnesses alleged to be caused by
If both the other coverage and we cover the same
Service, the other coverage and we will see that      third parties
up to 100 percent of your covered medical             If you obtain a judgment or settlement from or on
expenses are paid for that Service. The COB rules     behalf of a third party who allegedly caused an
determine which coverage pays first, or is            injury or illness for which you received covered
“primary,” and which coverage pays second, or is      Services, you must pay us Charges for those
“secondary.” The secondary coverage may               Services, except that the amount you must pay
reduce its payment to take into account payment       will not exceed the maximum amount allowed
by the primary coverage. You must give us any         under California Civil Code Section 3040.
information we request to help us coordinate          Note: This “Injuries or illnesses alleged to be
benefits.                                             caused by third parties” section does not affect
                                                      your obligation to pay Copayments and
If your coverage under this DF/EOC is                 Coinsurance for these Services, but we will credit
secondary, we may be able to establish a Benefit      any such payments toward the amount you must
Reserve Account for you. You may draw on the          pay us under this paragraph.
Benefit Reserve Account during a calendar year
to pay for your out-of-pocket expenses for            To the extent permitted or required by law, we
Services that are partially covered by either your    have the option of becoming subrogated to all
other coverage or us during that calendar year. If    claims, causes of action, and other rights you may
you are entitled to a Benefit Reserve Account, we     have against a third party or an insurer,
will provide you with detailed information about      government program, or other source of coverage
this account.                                         for monetary damages, compensation, or
                                                      indemnification on account of the injury or illness
                                                      allegedly caused by the third party. We will be so
                                                      subrogated as of the time we mail or deliver a

                                                                                                      45
written notice of our exercise of this option to         If your estate, parent, guardian, or conservator
you or your attorney, but we will be subrogated          asserts a claim against a third party based on your
only to the extent of the total of Charges for the       injury or illness, your estate, parent, guardian, or
relevant Services.                                       conservator and any settlement or judgment
                                                         recovered by the estate, parent, guardian, or
To secure our rights, we will have a lien on the         conservator shall be subject to our liens and other
proceeds of any judgment or settlement you or            rights to the same extent as if you had asserted
we obtain against a third party. The proceeds of         the claim against the third party. We may assign
any judgment or settlement that you or we obtain         our rights to enforce our liens and other rights.
shall first be applied to satisfy our lien, regardless
of whether the total amount of the proceeds is           If you are entitled to Medicare, Medicare law
less than the actual losses and damages you              may apply with respect to Services covered by
incurred.                                                Medicare.

Within 30 days after submitting or filing a claim        Some providers have contracted with Kaiser
or legal action against a third party, you must          Permanente to provide certain Services to
send written notice of the claim or legal action to:     Members at rates that are typically less than the
                                                         fees that the providers ordinarily charge to the
     For Northern California Members:
                                                         general public (“General Fees”). However, these
     Northern California Third Party Liability
                                                         contracts may allow the providers to recover all
     Supervisor
                                                         or a portion of the difference between the fees
     Kaiser Foundation Health Plan, Inc
                                                         paid by Kaiser Permanente and their General
     Special Recovery Unit
                                                         Fees by means of a lien claim under California
     Parsons East, Second Floor
                                                         Civil Code Sections 3045.1-3045.6 against a
     393 E. Walnut St.
                                                         judgment or settlement that you receive from or
     Pasadena, CA 91188
                                                         on behalf of a third party. For Services the
                                                         provider furnished, our recovery and the
     For Southern California Members:
                                                         provider’s recovery together will not exceed the
     Southern California Third Party Liability
                                                         provider’s General Fees.
     Supervisor
     Kaiser Foundation Health Plan, Inc
                                                         Medicare benefits
     Special Recovery Unit
     Parsons East, Second Floor                          Your benefits are reduced by any benefits to
     393 E. Walnut St.                                   which you are entitled under Medicare except for
     Pasadena, CA 91188                                  Members whose Medicare benefits are secondary
                                                         by law.
In order for us to determine the existence of any
rights we may have and to satisfy those rights,          Surrogacy arrangements
you must complete and send us all consents,              If you enter into a surrogacy arrangement, you
releases, authorizations, assignments, and other         must pay us Charges for covered Services you
documents, including lien forms directing your           receive related to conception, pregnancy, or
attorney, the third party, and the third party’s         delivery in connection with that arrangement
liability insurer to pay us directly. You may not        (“Surrogacy Health Services”), except that the
agree to waive, release, or reduce our rights under      amount you must pay will not exceed the
this provision without our prior, written consent.       compensation you are entitled to receive under
                                                         the surrogacy arrangement. A surrogacy

46
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


arrangement is one in which a woman agrees to       agree to waive, release, or reduce our rights under
become pregnant and to surrender the baby to        this provision without our prior, written consent.




                                                                                                          Part One − Basic Plan
another person or persons who intend to raise the
                                                    If your estate, parent, guardian, or conservator
child. Note: This “Surrogacy arrangements”
                                                    asserts a claim against a third party based on the
section does not affect your obligation to pay
                                                    surrogacy arrangement, your estate, parent,
Copayments and Coinsurance for these Services,
                                                    guardian, or conservator and any settlement or
but we will credit any such payments toward the
                                                    judgment recovered by the estate, parent,
amount you must pay us under this paragraph.
                                                    guardian, or conservator shall be subject to our
                                                    liens and other rights to the same extent as if you
By accepting Surrogacy Health Services, you
                                                    had asserted the claim against the third party. We
automatically assign to us your right to receive
                                                    may assign our rights to enforce our liens and
payments that are payable to you or your chosen
                                                    other rights.
payee under the surrogacy arrangement,
regardless of whether those payments are
                                                    U.S. Department of Veterans Affairs
characterized as being for medical expenses.
                                                    For any Services for conditions arising from
To secure our rights, we will also have a lien on   military service that the law requires the
those payments. Those payments shall first be       Department of Veterans Affairs to provide, we
applied to satisfy our lien. The assignment and     will not pay the Department of Veterans Affairs,
our lien will not exceed the total amount of your   and when we cover any such Services we may
obligation to us under the preceding paragraph.     recover the value of the Services from the
                                                    Department of Veterans Affairs.
Within 30 days after entering into a surrogacy
arrangement, you must send written notice of the    Workers’ compensation or employer’s liability
arrangement, including the names and addresses      benefits
of the other parties to the arrangement, and a      You may be eligible for payments or other
copy of any contracts or other documents            benefits, including amounts received as a
explaining the arrangement, to:                     settlement (collectively referred to as “Financial
                                                    Benefit”), under workers’ compensation or
   Surrogacy Third Party Liability Supervisor       employer’s liability law. We will provide covered
   Kaiser Foundation Health Plan, Inc.              Services even if it is unclear whether you are
   Special Recovery Unit                            entitled to a Financial Benefit, but we may
   Parsons East, Second Floor                       recover the value of any covered Services from
   393 E. Walnut St.                                the following sources:
   Pasadena, CA 91188                               • From any source providing a Financial Benefit
                                                      or from whom a Financial Benefit is due
You must complete and send us all consents,
                                                    • From you, to the extent that a Financial
releases, authorizations, lien forms, and other
                                                      Benefit is provided or payable or would have
documents that are reasonably necessary for us to
                                                      been required to be provided or payable if you
determine the existence of any rights we may
                                                      had diligently sought to establish your rights to
have under this “Surrogacy arrangements”
                                                      the Financial Benefit under any workers’
section and to satisfy those rights. You may not
                                                      compensation or employer’s liability law




                                                                                                     47
REQUESTS FOR PAYMENT OR SERVICES

Requests for Payment                                     free at 800-464-4000 or 800-390-3510 (TTY
                                                         users call 800-777-1370). One of our
Emergency, Post-Stabilization, or Out-of-Area            representatives will be happy to assist you
Urgent Care                                              if you need help completing our claim form
If you receive Emergency Care,
                                                       • If you have paid for Services, you must send
Post-Stabilization Care, or Out-of-Area Urgent
                                                         us our completed claim form for
Care from a Non–Plan Provider as described in
                                                         reimbursement. Please attach any bills and
the “Emergency, Post-Stabilization, and
                                                         receipts from the Non–Plan Provider
Out-of-Area Urgent Care from Non–Plan
Providers” section, you must pay for the Services      • To request that a Non–Plan Provider be paid
unless the Non–Plan Provider agrees to bill us. If       for Services, you must send us our completed
you want us to pay for the Services, you must file       claim form and include any bills from the
a claim. Also, if you receive Services from a Plan       Non–Plan Provider. If the Non–Plan Provider
Provider that are prescribed by a Non–Plan               states that they will submit the claim, you are
Provider in conjunction with covered Emergency,          still responsible for making sure that we
Post-Stabilization, and Out-of-Area Urgent Care,         receive everything we need to process the
you may be required to pay for the Services and          request for payment. If you later receive any
file a claim. We will reduce any payment we              bills from the Non–Plan Provider for covered
make to you or the Non–Plan Provider by the              Services other than your Copayments and
applicable Copayments and Coinsurance.                   Coinsurance amount, please call our Member
                                                         Service Call Center toll free at 800-390-3510
We will send you our written decision within             for assistance
30 days after we receive the claim from you or         • You must complete and return to us any
the Non–Plan Provider unless we notify you,              information that we request to process your
within that initial 30 days, that we need additional     claim, such as claim forms, consents for the
information from you or the Non–Plan Provider.           release of medical records, assignments, and
We must receive the additional information               claims for any other benefits to which you may
within 45 days of our request in order for the           be entitled. For example, we may require
information to be considered in our decision. We         documents such as travel documents or
will send you our written decision within 15 days        original travel tickets to validate your claim
of receiving the additional information. However,      • The completed claim form must be mailed to
if we don’t receive the additional information           the following address as soon as possible after
within 45 days of our request, we will send you          receiving the care. Any additional information
our written decision no later than 90 days from          we request should also be mailed to this
the date of your initial request for payment.            address:

If our decision is not fully in your favor, we will          For Northern California Members:
tell you the reasons and how to file a grievance.            Kaiser Foundation Health Plan, Inc.
                                                             Claims Department
How to file a claim. To file a claim, this is what           P.O. Box 12923
you need to do:                                              Oakland, CA 94604-2923

• As soon as possible, request our claim form by
  calling our Member Service Call Center toll

48
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


      For Southern California Members:              Services Department at a Plan Facility. You will
Kaiser Foundation Health Plan, Inc.                 receive a written decision within 15 days unless




                                                                                                          Part One − Basic Plan
Claims Department                                   you are notified that additional information is
P.O. Box 7004                                       needed. The additional information must be
Downey, CA 90242-7004                               received within 45 days of the request for
                                                    information in order for it to be considered in the
Other Services                                      decision. You will receive a written decision
                                                    within 15 days after we receive the additional
To request payment for Services that you believe
                                                    information. If you don’t supply the additional
should be covered, other than the Services
                                                    information within 45 days of the request, you
described above, you must submit a written
                                                    will receive a written decision no later than
request to your local Member Services
                                                    75 days after the date you made your request to
Department at a Plan Facility. Please attach any
                                                    Member Services. If we do not approve your
bills and receipts if you have paid any bills.
                                                    request, we will send you a written decision that
                                                    tells you the reasons and how to file a grievance.
We will send you our written decision within
30 days unless we notify you, within that initial
                                                    If you believe we should cover a Medically
30 days, that we need additional information
                                                    Necessary Service that is not covered under this
from you or the Non–Plan Provider. We must
                                                    DF/EOC, you may file a grievance as described
receive the additional information within 45 days
                                                    in the “Dispute Resolution” section.
of our request in order for the information to be
considered in our decision. We will send you our
written decision within 15 days of receiving the    Expedited decision
additional information. However, if we don’t        You or your physician may make an oral or
receive the additional information within 45 days   written request that we expedite our decision
of our request, we will send you our written        about your request for Services if it involves an
decision no later than 90 days from the date of     imminent and serious threat to your health, such
your initial request for payment.                   as severe pain or potential loss of life, limb, or
                                                    major bodily function. We will inform you of our
If we do not approve your request, we will tell     decision within 72 hours (orally or in writing).
you the reasons and how to file a grievance.
                                                    If the request is for a continuation of an expiring
Requests for Services                               course of treatment and you make the request at
                                                    least 24 hours before the treatment expires, we
Standard decision                                   will inform you of our decision within 24 hours.
If you have received a written denial of Services
from the Medical Group or a “Notice of Non-         You or your physician must request an expedited
Coverage” and you want to request that we cover     decision in one of the following ways and you
the Services, you must file a grievance as          must specifically state that you want an expedited
described in the “Dispute Resolution” section       decision:
within 180 days of the date you received the        • Call our Expedited Review Unit toll free at
denial.                                               888-987-7247 (TTY users call 800-777-1370),
                                                      which is available Monday through Saturday
If you haven’t received a written denial of           from 8:30 a.m. to 5 p.m. After hours, you may
Services, you may make a request for Services
orally or in writing to your local Member

                                                                                                     49
     leave a message and a representative will   will respond to your request for Services as
     return your call the next business day      described under “Standard decision.” If we do not
• Send your written request to:                  approve your request, we will send you a written
     Kaiser Foundation Health Plan, Inc.         decision that tells you the reasons and how to file
     Expedited Review Unit                       a grievance.
     P.O. Box 23170
     Oakland, CA 94623-0170                      Note: If you have an issue that involves an
                                                 imminent and serious threat to your health (such
• Fax your written request to our Expedited      as severe pain or potential loss of life, limb, or
  Review Unit toll free at 888-987-2252          major bodily function), you can contact the
• Deliver your request in person to your local   California Department of Managed Health Care
  Member Services Department at a Plan           (DMHC) directly at any time without first filing a
  Facility                                       grievance with us.

If we do not approve your request for an
expedited decision, we will notify you and we




50
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


DISPUTE RESOLUTION




                                                                                                          Part One − Basic Plan
Grievances                                          will send you our written decision within 30 days
                                                    after we receive your grievance. If we do not
We are committed to providing you with quality
                                                    approve your request, we will tell you the reasons
care and with a timely response to your concerns.
                                                    and about additional dispute resolution options.
You can discuss your concerns with our Member
                                                    Note: If we resolve your issue to your satisfaction
Services representatives at most Plan Facilities,
                                                    by the end of the next business day after we
or you can call our Member Service Call Center.
                                                    receive your grievance and a Member Services
                                                    representative notifies you orally about our
You can file a grievance for any issue. Your
                                                    decision, we will not send you a confirmation
grievance must explain your issue, such as the
                                                    letter or a written decision unless your grievance
reasons why you believe a decision was in error
                                                    involves a coverage dispute, a dispute about
or why you are dissatisfied about Services you
                                                    whether a Service is Medically Necessary, or an
received. You must submit your grievance orally
                                                    experimental or investigational treatment.
or in writing within 180 days of the date of the
incident that caused your dissatisfaction as
                                                    Expedited grievance
follows:
                                                    You or your physician may make an oral or
• To a Member Services representative at your       written request that we expedite our decision
  local Member Services Department at a Plan
                                                    about your grievance if it involves an imminent
  Facility (please refer to Your Guidebook for
                                                    and serious threat to your health, such as severe
  locations), or by calling our Member Service
                                                    pain or potential loss of life, limb, or major
  Call Center
                                                    bodily function. We will inform you of our
• Through our Web site at kp.org                    decision within 72 hours (orally or in writing).
• To the following location for claims described
  under “Emergency, Post-Stabilization, or Out-     We will also expedite our decision if the request
  of-Area Urgent Care” under “Requests for          is for a continuation of an expiring course of
  Payment” in the “Requests for Payment or          treatment.
  Services” section:
                                                    You or your physician must request an expedited
      For Northern California Members:              decision in one of the following ways and you
      Kaiser Foundation Health Plan, Inc.           must specifically state that you want an expedited
      Special Services Unit                         decision:
      P.O. Box 23280
      Oakland, CA 94623                             • Call our Expedited Review Unit toll free at
                                                      888-987-7247 (TTY users call 800-777-1370),
      For Southern California Members:                which is available Monday through Saturday
      Kaiser Foundation Health Plan, Inc.             from 8:30 a.m. to 5 p.m. After hours, you may
      Special Services Unit                           leave a message and a representative will
      P.O. Box 7136                                   return your call the next business day
      Pasadena, CA 91109

We will send you a confirmation letter within
five days after we receive your grievance. We


                                                                                                    51
• Send your written request to:                      • You may file for yourself
      Kaiser Foundation Health Plan, Inc.            • You may appoint someone as your authorized
      Expedited Review Unit                            representative by completing our authorization
      P.O. Box 23170                                   form. Authorization forms are available from
      Oakland, CA 94623-0170                           your local Member Services Department at a
• Fax your written request to our Expedited            Plan Facility or by calling our Member Service
  Review Unit toll free at 888-987-2252                Call Center. Your completed authorization
• Deliver your request in person to your local         form must accompany the grievance
  Member Services Department at a Plan               • You may file for your Dependent under age
  Facility                                             18, except that he or she must appoint you as
                                                       his or her authorized representative if he or she
If we do not approve your request for an               has the legal right to control release of
expedited decision, we will notify you and we          information that is relevant to the grievance
will respond to your grievance within 30 days. If    • You may file for your ward if you are a court-
we do not approve your grievance, we will send         appointed guardian, except that he or she must
you a written decision that tells you the reasons      appoint you as his or her authorized
and about additional dispute resolution options.       representative if he or she has the legal right to
                                                       control release of information that is relevant
Note: If you have an issue that involves an            to the grievance
imminent and serious threat to your health (such
                                                     • You may file for your conservatee if you are a
as severe pain or potential loss of life, limb, or
                                                       court-appointed conservator
major bodily function), you can contact the
DMHC directly at any time without first filing a     • You may file for your principal if you are an
grievance with us.                                     agent under a currently effective health care
                                                       proxy, to the extent provided under state law
Supporting Documents                                 • Your physician may request an expedited
It is helpful for you to include any information       grievance as described under “Expedited
that clarifies or supports your position. You may      grievance” in this “Dispute Resolution”
want to include supporting information with your       section
grievance, such as medical records or physician
opinions. When appropriate, we will request          DMHC Complaints
medical records from Plan Providers on your          The California Department of Managed Health
behalf. If you have consulted with a Non–Plan        Care is responsible for regulating health care
Provider and are unable to provide copies of         service plans. If you have a grievance against
relevant medical records, we will contact the        your health plan, you should first telephone your
provider to request a copy of your medical           health plan toll free at 800-464-4000 (TTY users
records. We will ask you to send or fax us a         call 800-777-1370) and use your health plan’s
written authorization so that we can request your    grievance process before contacting the
records. If we do not receive the information we     department. Utilizing this grievance procedure
request in a timely fashion, we will make a          does not prohibit any potential legal rights or
decision based on the information we have.           remedies that may be available to you. If you
                                                     need help with a grievance involving an
Who May File                                         emergency, a grievance that has not been
The following persons may file a grievance:          satisfactorily resolved by your health plan, or a
                                                     grievance that has remained unresolved for more
52
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


than 30 days, you may call the department for        • Your request for payment or Services has been
assistance. You may also be eligible for an            denied, modified, or delayed based in whole or




                                                                                                           Part One − Basic Plan
Independent Medical Review (IMR). If you are           in part on a decision that the Services are not
eligible for IMR, the IMR process will provide an      Medically Necessary
impartial review of medical decisions made by a      • You have filed a grievance and we have
health plan related to the medical necessity of a      denied it or we haven’t made a decision about
proposed service or treatment, coverage decisions      your grievance within 30 days (or three days
for treatments that are experimental or                for expedited grievances). The DMHC may
investigational in nature and payment disputes for     waive the requirement that you first file a
emergency or urgent medical services. The              grievance with us in extraordinary and
department also has a toll-free telephone number       compelling cases, such as severe pain or
(888-HMO-2219) and a TDD line                          potential loss of life, limb, or major bodily
(877-688-9891) for the hearing and speech              function
impaired. The department’s Internet Web site
http://www.hmohelp.ca.gov has complaint              You may also qualify for IMR if the Service you
forms, IMR application forms and instructions        requested has been denied on the basis that it is
online.                                              experimental or investigational as described
                                                     under “Experimental or investigational denials”.
Independent Medical Review (IMR)
If you qualify, you or your authorized               If the DMHC determines that your case is eligible
representative may have your issue reviewed          for IMR, it will ask us to send your case to the
through the Independent Medical Review (IMR)         DMHC’s Independent Medical Review
process managed by the California Department of      organization. The DMHC will promptly notify
Managed Health Care (DMHC). The DMHC                 you of its decision after it receives the
determines which cases qualify for IMR. This         Independent Medical Review organization’s
review is at no cost to you. If you decide not to    determination. If the decision is in your favor, we
request an IMR, you may give up the right to         will contact you to arrange for the Service or
pursue some legal actions against us.                payment.

You may qualify for IMR if all of the following      Experimental or investigational denials
are true:                                            If we deny a Service because it is experimental or
• One of these situations applies to you:            investigational, we will send you our written
                                                     explanation within five days of making our
  ♦ you have a recommendation from a
                                                     decision. We will explain why we denied the
    provider requesting Medically Necessary
                                                     Service and provide additional dispute resolution
    Services
                                                     options. Also, we will provide information about
  ♦ you have received Emergency Care or              your right to request Independent Medical
    Urgent Care from a provider who                  Review if we had the following information when
    determined the Services to be Medically          we made our decision:
    Necessary
                                                     • Your treating physician provided us a written
  ♦ you have been seen by a Plan Provider for
                                                       statement that you have a life-threatening or
    the diagnosis or treatment of your medical
                                                       seriously debilitating condition and that
    condition
                                                       standard therapies have not been effective in
                                                       improving your condition, or that standard


                                                                                                     53
     therapies would not be appropriate, or that        Eligibility
     there is no more beneficial standard therapy       Issues of eligibility must be referred directly to
     we cover than the therapy being requested.         CalPERS. Contact the CalPERS Office of
     “Life-threatening” means diseases or               Employer and Member Health Services at P.O.
     conditions where the likelihood of death is        Box 942714, Sacramento, CA 94229-2714, fax
     high unless the course of the disease is           number 916-795-1277, or telephone the CalPERS
     interrupted, or diseases or conditions with        Customer Service and Education Division toll
     potentially fatal outcomes where the end point     free at 888-CalPERS (888-225-7377).
     of clinical intervention is survival. “Seriously
     debilitating” means diseases or conditions that    Coverage
     cause major irreversible morbidity
                                                        A coverage issue concerns the denial of Services
• If your treating physician is a Plan Physician,       substantially based on a finding that the provision
  he or she recommended a treatment, drug,              of a particular Service is excluded as a covered
  device, procedure, or other therapy and               benefit under this DF/EOC. It does not include a
  certified that the requested therapy is likely to     Plan Provider’s decision about a disputed
  be more beneficial to you than any available          Service.
  standard therapies and included a statement of
  the evidence relied upon by the Plan Physician        If you are dissatisfied with the outcome of our
  in certifying his or her recommendation               grievance process or if you have been in the
• You (or your Non–Plan Physician who is a              process for 30 days or more, you may request
  licensed, and either a board-certified or board-      review by the Department of Managed Health
  eligible, physician qualified in the area of          Care (DMHC) or you may request an
  practice appropriate to treat your condition)         administrative review through the CalPERS
  requested a therapy that, based on two                Board of Administration. As an alternative to the
  documents from the medical and scientific             administrative review process, you may submit
  evidence, as defined in California Health and         the matter to binding arbitration (or Small Claims
  Safety Code Section 1370.4(d), is likely to be        Court if applicable) or the Department of
  more beneficial for you than any available            Managed Health Care. However, you must
  standard therapy. The physician’s certification       choose between the CalPERS administrative
  included a statement of the evidence relied           review process, DMHC, arbitration (or Small
  upon by the physician in certifying his or her        Claims Court if applicable). You may not take the
  recommendation. We do not cover the                   issue to the CalPERS Board and the other
  Services of the Non–Plan Provider                     procedures.

Note: You can request IMR for experimental or           Independent medical review
investigational denials at any time without first       If you are dissatisfied with the outcome of the
filing a grievance with us.                             independent medical review process described
                                                        under the “Independent Medical Review (IMR)”
CalPERS Administrative Review                           section, you may request an administrative
If you do not achieve resolution of your                review through the CalPERS Board of
complaint through the grievance process                 Administration, or you may submit the matter to
described under “Grievances” or “Independent            binding arbitration (or Small Claims Court if
Medical Review (IMR),” you have additional              applicable).
dispute resolution options, depending on the
nature of the complaint.

54
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


CalPERS administrative review process                application shall be binding only on the Kaiser
CalPERS staff may conduct an administrative          Permanente Parties.




                                                                                                            Part One − Basic Plan
review of your dispute if we deny your grievance
or if the Department of Managed Health Care          Scope of Arbitration
denies your IMR request. However, your written       Any dispute shall be submitted to binding
request must be submitted to CalPERS within          arbitration if all of the following requirements are
30 days of the date of our denial letter or the      met:
Department of Managed Health Care’s                  • The claim arises from or is related to an
determination of findings.                             alleged violation of any duty incident to or
                                                       arising out of or relating to this DF/EOC or a
If the dispute remains unresolved during the           Member Party’s relationship to Kaiser
administrative review process, the matter may          Foundation Health Plan, Inc. (Health Plan),
proceed to an Administrative Hearing. During the       including any claim for medical or hospital
hearing, evidence and testimony will be presented      malpractice (a claim that medical services
to an Administrative Law Judge. As an                  were unnecessary or unauthorized or were
alternative to this hearing, you may have recourse     improperly, negligently, or incompetently
through binding arbitration (or Small Claims           rendered), for premises liability, or relating to
Court if applicable). However, you must choose         the coverage for, or delivery of, Services,
between the Administrative Hearing and binding         irrespective of the legal theories upon which
arbitration (or Small Claims Court if applicable).     the claim is asserted
You may not take the same issue through both
                                                     • The claim is asserted by one or more Member
procedures. You may withdraw your request from
                                                       Parties against one or more Kaiser Permanente
CalPERS at any time, and proceed to binding
                                                       Parties or by one or more Kaiser Permanente
arbitration (or Small Claims Court if applicable).
                                                       Parties against one or more Member Parties
To request an administrative review, please          • The claim is not within the jurisdiction of the
contact CalPERS Office of Employer and                 Small Claims Court
Member Health Services at P.O. Box 942714,           • If your Group must comply with the Employee
Sacramento, CA 94229-2714, fax number                  Retirement Income Security Act (ERISA)
916-795-1277, or telephone the CalPERS                 requirements, the claim is not a benefit-related
Customer Service and Education Division toll           request that constitutes a “benefit claim” in
free at 888-CalPERS (888-225-7377).                    Section 502(a)(1)(B) of ERISA. Note: Benefit
                                                       claims under this section of ERISA are
Binding Arbitration                                    excluded from this binding arbitration
For all claims subject to this “Binding                requirement only until such time as the United
Arbitration” section, both Claimants and               States Department of Labor regulation
                                                       prohibiting mandatory binding arbitration of
Respondents give up the right to a jury or court
                                                       this category of claim (29 CFR 2560.503-
trial and accept the use of binding arbitration.
                                                       1(c)(4)) is modified, amended, repealed,
Insofar as this “Binding Arbitration” section
                                                       superseded, or otherwise found to be invalid.
applies to claims asserted by Kaiser Permanente
                                                       If this occurs, these claims will automatically
Parties, it shall apply retroactively to all
                                                       become subject to mandatory binding
unresolved claims that accrued before the
                                                       arbitration without further notice
effective date of this DF/EOC. Such retroactive



                                                                                                       55
As referred to in this “Binding Arbitration”        include all claims against Respondents that are
section, “Member Parties” include:                  based on the same incident, transaction, or related
• A Member                                          circumstances in the Demand for Arbitration.
• A Member’s heir, relative, or personal
                                                    Serving Demand for Arbitration
  representative
                                                    Health Plan, KFH, KP Cal, TPMG, SCPMG, The
• Any person claiming that a duty to him or her     Permanente Federation, LLC, and The
  arises from a Member’s relationship to one or     Permanente Company, LLC shall be served with
  more Kaiser Permanente Parties                    a Demand for Arbitration by mailing the Demand
                                                    for Arbitration addressed to that Respondent in
“Kaiser Permanente Parties” include:                care of:
• Kaiser Foundation Health Plan, Inc. (Health         For Northern California Members:
  Plan)                                               Kaiser Foundation Health Plan, Inc.
• Kaiser Foundation Hospitals (KFH)                   Legal Department
• KP Cal, LLC (KP Cal)                                1950 Franklin St, 17th Floor
                                                      Oakland, CA 94612
• The Permanente Medical Group, Inc. (TPMG)
• Southern California Permanente Medical              For Southern California Members:
  Group (SCPMG)                                       Kaiser Foundation Health Plan, Inc.
• The Permanente Federation, LLC                      Legal Department
                                                      393 E. Walnut St
• The Permanente Company, LLC
                                                      Pasadena, CA 91188
• Any KFH, TPMG, or SCPMG physician
• Any individual or organization whose contract     Service on that Respondent shall be deemed
  with any of the organizations identified above    completed when received. All other Respondents,
  requires arbitration of claims brought by one     including individuals, must be served as required
  or more Member Parties                            by the California Code of Civil Procedure for a
                                                    civil action.
• Any employee or agent of any of the foregoing
                                                    Filing Fee
“Claimant” refers to a Member Party or a Kaiser
Permanente Party who asserts a claim as             The Claimants shall pay a single, nonrefundable,
described above. “Respondent” refers to a           filing fee of $150 per arbitration payable to
Member Party or a Kaiser Permanente Party           “Arbitration Account” regardless of the number
against whom a claim is asserted.                   of claims asserted in the Demand for Arbitration
                                                    or the number of Claimants or Respondents
                                                    named in the Demand for Arbitration.
Initiating Arbitration
Claimants shall initiate arbitration by serving a
                                                    Any Claimant who claims extreme hardship may
Demand for Arbitration. The Demand for
                                                    request that the Office of the Independent
Arbitration shall include the basis of the claim
                                                    Administrator waive the filing fee and the neutral
against the Respondents; the amount of damages
                                                    arbitrators’ fees and expenses. A Claimant who
the Claimants seek in the arbitration; the names,
                                                    seeks such waivers shall complete the Fee Waiver
addresses, and telephone numbers of the
                                                    Form and submit it to the Office of the
Claimants and their attorney, if any; and the
                                                    Independent Administrator and simultaneously
names of all Respondents. Claimants shall
                                                    serve it upon the Respondents. The Fee Waiver

56
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Form sets forth the criteria for waiving fees and is   Costs
available by calling our Member Service Call           Except for the aforementioned fees and expenses




                                                                                                             Part One − Basic Plan
Center.                                                of the neutral arbitrator, and except as otherwise
                                                       mandated by laws that apply to arbitrations under
Number of Arbitrators                                  this “Binding Arbitration” section, each party
The number of Arbitrators may affect the               shall bear the party’s own attorneys’ fees, witness
Claimant’s responsibility for paying the neutral       fees, and other expenses incurred in prosecuting
arbitrator’s fees and expenses.                        or defending against a claim regardless of the
                                                       nature of the claim or outcome of the arbitration.
If the Demand for Arbitration seeks total
damages of $200,000 or less, the dispute shall be      Rules of Procedure
heard and determined by one neutral arbitrator,        Arbitrations shall be conducted according to the
unless the parties otherwise agree in writing that     Rules of Procedure developed by the Office of
the arbitration shall be heard by two party            the Independent Administrator in consultation
arbitrators and one neutral arbitrator. The neutral    with Kaiser Permanente and the Arbitration
arbitrator shall not have authority to award           Oversight Board. Copies of the Rules of
monetary damages that are greater than $200,000.       Procedure may be obtained from our Member
                                                       Service Call Center.
If the Demand for Arbitration seeks total
damages of more than $200,000, the dispute shall       General Provisions
be heard and determined by one neutral arbitrator
                                                       A claim shall be waived and forever barred if
and two party arbitrators, one jointly appointed
                                                       (1) on the date the Demand for Arbitration of the
by all Claimants and one jointly appointed by all
                                                       claim is served, the claim, if asserted in a civil
Respondents. Parties who are entitled to select a
                                                       action, would be barred as to the Respondents
party arbitrator may agree to waive this right. If
                                                       served by the applicable statute of limitations,
all parties agree, these arbitrations will be heard
                                                       (2) Claimants fail to pursue the arbitration claim
by a single neutral arbitrator.
                                                       in accord with the Rules of Procedure with
                                                       reasonable diligence, or (3) the arbitration
Payment of Arbitrators’ Fees and Expenses              hearing is not commenced within five years after
Health Plan will pay the fees and expenses of the      the earlier of (a) the date the Demand for
neutral arbitrator under certain conditions as set     Arbitration was served in accord with the
forth in the Rules for Kaiser Permanente Member        procedures prescribed herein, or (b) the date of
Arbitrations Overseen by the Office of the             filing of a civil action based upon the same
Independent Administrator (“Rules of                   incident, transaction, or related circumstances
Procedure”). In all other arbitrations, the fees and   involved in the claim. A claim may be dismissed
expenses of the neutral arbitrator shall be paid       on other grounds by the neutral arbitrator based
one-half by the Claimants and one-half by the          on a showing of a good cause. If a party fails to
Respondents.                                           attend the arbitration hearing after being given
                                                       due notice thereof, the neutral arbitrator may
If the parties select party arbitrators, Claimants     proceed to determine the controversy in the
shall be responsible for paying the fees and           party’s absence.
expenses of their party arbitrator and
Respondents shall be responsible for paying the        The California Medical Injury Compensation
fees and expenses of their party arbitrator.           Reform Act of 1975 (including any amendments


                                                                                                       57
thereto), including sections establishing the right   Arbitrations shall be governed by this “Binding
to introduce evidence of any insurance or             Arbitration” section, Section 2 of the Federal
disability benefit payment to the patient, the        Arbitration Act, and the California Code of Civil
limitation on recovery for noneconomic losses,        Procedure provisions relating to arbitration that
and the right to have an award for future damages     are in effect at the time the statute is applied,
conformed to periodic payments, shall apply to        together with the Rules of Procedure, to the
any claims for professional negligence or any         extent not inconsistent with this “Binding
other claims as permitted or required by law.         Arbitration” section.




58
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


TERMINATION OF MEMBERSHIP




                                                                                                            Part One − Basic Plan
Your Group is required to inform the Subscriber          your coverage under the newly chosen
of the date your membership terminates. The              CalPERS-sponsored plan will take effect)
guidelines that determine the termination of           • Your membership terminated for a reason
coverage from the CalPERS Health Program are             other than termination of your Group’s
governed in accord with the Public Employees’            Agreement with us or voluntary termination by
Medical & Hospital Care Act (PEMHCA). For an             the Subscriber
explanation of specific eligibility criteria and
termination requirements, please consult your          Termination Due to Loss of Eligibility
Health Benefits Officer (or, if you are retired, the
CalPERS Office of Employer and Member                  If you meet the eligibility requirements described
Health Services). Your CalPERS Health                  under “Eligibility” in the “Premiums, Eligibility,
Program Guide also includes eligibility and            and Enrollment” section on the first day of a
termination information and can be ordered             month, but later in that month you no longer meet
through the CalPERS Web site or by calling             those eligibility requirements, your membership
CalPERS.                                               will end at 11:59 p.m. on the last day of that
                                                       month. For example, if you become ineligible on
Your membership termination date is the first day      December 5, 2009, your termination date is
you are not covered (for example, if your              January 1, 2010 and your last minute of coverage
termination date is January 1, 2010, your last         is at 11:59 p.m. on December 31, 2009.
minute of coverage was at 11:59 p.m. on
December 31, 2009). When a Subscriber’s                Termination of Agreement
membership ends, the memberships of any                If your Group’s Agreement with us terminates for
Dependents end at the same time. You will be           any reason, your membership ends on the same
billed as a non-Member for any Services you            date. Your Group is required to notify
receive after your membership terminates.              Subscribers in writing if its Agreement with us
                                                       terminates.
Health Plan and Plan Providers have no further
liability or responsibility under this DF/EOC          Termination for Cause
after your membership terminates, except as
provided under “Payments after Termination” in         If you commit one of the following acts, we will
this “Termination of Membership” section, or if        ask CalPERS to approve termination of your
your coverage terminates for one of the reasons        membership in accord with Section 22841 of the
listed below and you are receiving covered             Government Code. If CalPERS approves
Services as an acute care hospital inpatient on the    termination of your membership, CalPERS will
termination date, we will continue to cover your       send written notice to the Subscriber:
hospital Services until you are discharged. We         • Your behavior threatens the safety of Plan
will cover only 91 days of continuous                    personnel or of any person or property at a
hospitalization after the termination date if one of     Plan Facility
the following is true:
                                                       • You commit theft from Health Plan, from a
• Your membership terminated due to a change             Plan Provider, or at a Plan Facility
  from one CalPERS-sponsored plan to another
  (if you are still hospitalized on the 92nd day,


                                                                                                       59
• You intentionally commit fraud in connection         Coverage” to Members whose coverage
  with membership, Health Plan, or a Plan              terminates. The certificate documents health care
  Provider. Some examples of fraud include:            coverage and you can use it to prove prior
  ♦ misrepresenting eligibility information            creditable health care coverage if you seek new
    about you or a Dependent                           coverage after your membership terminates.
  ♦ presenting an invalid prescription or
                                                       When your membership terminates, or at any
    physician order                                    time upon request, we will mail the certificate to
                                                       the Subscriber unless your Group has an
  ♦ misusing a Kaiser Permanente ID card (or
                                                       agreement with us to mail the certificates. If you
    letting someone else use it)                       have any questions, please contact your Group’s
  ♦ giving us incorrect or incomplete material         Health Benefits Officer (or, if you are retired, the
    information                                        CalPERS Office of Employer and Member
  ♦ failing to notify us of changes in family          Health Services).
    status or Medicare coverage that may affect
    your eligibility or benefits                       Payments after Termination
                                                       If we terminate your membership for cause, we
If we terminate your membership for cause, you
                                                       will:
will not be allowed to enroll in Health Plan in the
future. We may also report criminal fraud and          • Refund any amounts we owe your Group for
other illegal acts to the authorities for                Premiums paid after the termination date
prosecution.                                           • Pay you any amounts we have determined that
                                                         we owe you for claims during your
Termination of a Product or all Products                 membership in accord with “Requests for
                                                         Payment” in the “Requests for Payment or
We may terminate a particular product or all
                                                         Services” section. We will deduct any amounts
products offered in a small or large group market
                                                         you owe Health Plan or Plan Providers from
as permitted or required by law. If we discontinue
                                                         any payment we make to you
offering a particular product in a market, we will
terminate just the particular product upon 90 days
prior written notice to you. If we discontinue         State Review of Membership
offering all products to groups in a small or large    Termination
group market, as applicable, we may terminate          If you believe that we terminated your
your Group’s Agreement upon 180 days prior             membership because of your ill health or your
written notice to you.                                 need for care, you may request a review of the
                                                       termination by the California Department of
HIPPA Certificates of Creditable                       Managed Health Care (please see “DMHC
Coverage                                               Complaints” in the “Dispute Resolution”
The Health Insurance Portability and                   section).
Accountability Act (HIPAA) requires employers
or health plans to issue “Certificates of Creditable




60
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


CONTINUATION OF MEMBERSHIP




                                                                                                       Part One − Basic Plan
If your membership under this DF/EOC ends,           coverage, when coverage and Premiums may
you may be eligible to maintain Health Plan          change, and where to send your Premium
membership without a break in coverage under         payments.
this DF/EOC (Group coverage) or you may be
eligible to convert to an individual (nongroup)      As described in “Conversion from Group
plan.                                                Membership to an Individual Plan” in this
                                                     “Continuation of Membership” section, you may
Continuation of Group Coverage                       be able to convert to an individual (nongroup)
                                                     plan if you don’t apply for COBRA coverage, or
If at any time you become entitled to continuation
                                                     if you enroll in COBRA and your COBRA
of Group coverage such as Cal-COBRA, please
                                                     coverage ends. Also, if you enroll in COBRA and
examine your coverage options carefully before
                                                     exhaust the time limit for COBRA coverage, you
declining this coverage. You should be aware that
                                                     may be able to continue Group coverage under
companies selling individual health insurance
                                                     state law as described in “COBRA extension
typically require a review of your medical history
                                                     (Cal-COBRA),” below.
that could result in a higher premium or you
could be denied coverage entirely.
                                                     COBRA extension (Cal-COBRA)
Note: Medical history does not impact premiums
                                                     In certain cases, if you would otherwise lose
or eligibility for our Individual–Conversion Plan
                                                     COBRA coverage, you may be able to continue
and HIPAA Individual Plan described under
                                                     uninterrupted Group coverage under this
“Conversion from Group Membership to an
                                                     DF/EOC for a limited time upon arrangement
Individual Plan” in this “Continuation of
                                                     with us in compliance with Cal-COBRA if all of
Membership” section. However, the individual
                                                     the following are true:
plan premiums and coverage will be different
from the premiums and coverage under your            • Your effective date of COBRA coverage was
Group plan.                                            on or after January 1, 2003
                                                     • You have exhausted the time limit for COBRA
COBRA                                                  coverage and that time limit was 18 or 29
You may be able to continue your coverage under        months
this DF/EOC for a limited time after you would       • You are not entitled to Medicare
otherwise lose eligibility, if required by the
                                                     • You pay us monthly premiums by the billing
federal COBRA law. COBRA applies to most
                                                       due date described under “How to request
employees (and most of their covered family
                                                       Cal-COBRA enrollment and paying
Dependents) of most employers with 20 or more
                                                       premiums”
employees.
                                                     As described in “Conversion from Group
You must submit a COBRA election form to your
                                                     Membership to an Individual Plan” in this
Group within the COBRA election period. Please
                                                     “Continuation of Membership” section, you may
ask your Health Benefits Officer (or, if you are
                                                     be able to convert to an individual (nongroup)
retired, the CalPERS Office of Employer and
                                                     plan if you don’t apply for Cal-COBRA
Member Health Services) for details about
                                                     coverage, or if you enroll in Cal-COBRA and
COBRA coverage, such as how to elect coverage,
                                                     your Cal-COBRA coverage ends.
how much you must pay your Group for

                                                                                                 61
How to request Cal-COBRA enrollment and              Group makes a change that affects premiums
paying premiums. To request an enrollment            retroactively, the amount we bill you will be
application, please call our Member Service Call     adjusted to reflect the retroactive adjustment in
Center. Within 10 days of your request, we will      premiums. Your Health Benefits Officer (or, if
send you our enrollment application, which will      you are retired, the CalPERS Office of Employer
include premiums and billing information. You        and Member Health Services) can tell you
must return your completed enrollment                whether this DF/EOC is still in effect and give
application within 63 days of the date of our        you a current one if this DF/EOC has expired or
termination letter or of your membership             been amended. You can also request one from
termination date (whichever date is later).          our Member Service Call Center.

If we approve your enrollment application, we        Termination of Cal-COBRA coverage.
will send you a bill within 30 days after we         Cal-COBRA coverage continues only upon
receive your application. You must pay the bill      payment of applicable monthly premiums to us at
within 45 days after the date we issue the bill.     the time we specify, and terminates on the earliest
The first premium payment will include coverage      of:
from when you exhausted COBRA coverage               • The date your Group’s Agreement with us
through our current billing cycle. You must send       terminates (you may still be eligible for
us the premium payment (including the                  Cal-COBRA through another group health
administrative fee) by the due date on the bill to     plan)
be enrolled in Cal-COBRA.
                                                     • The date you become entitled to Medicare
After that first payment, monthly premium            • The date your coverage begins under any other
payments (including the administrative fee) are        group health plan that does not contain any
due on or before the last day of the month             exclusion or limitation with respect to any pre-
preceding the month of coverage. The premiums          existing condition you may have (or that does
will not exceed 110 percent of the applicable          contain such an exclusion or limitation, but it
Premiums charged to a similarly situated               has been satisfied)
individual under the Group benefit plan except       • Expiration of 36 months after your original
that premiums for disabled individuals after 18        COBRA effective date (under this or any other
months of COBRA coverage will not exceed 150           plan)
percent instead of 110 percent.
                                                     • The date your membership is terminated for
                                                       nonpayment of premiums as described under
Changes to Cal-COBRA coverage and
                                                       “Termination for nonpayment of Cal-COBRA
premiums. Your Cal-COBRA coverage and
                                                       premiums” in this “Continuation of
premiums are the same as for any similarly
                                                       Membership” section
situated individual under your Group's
Agreement, and will change at the same time that
                                                     Note: If the Social Security Administration
coverage or Premiums change in your Group's
                                                     determined that you were disabled at any time
Agreement. Your Group’s coverage and
                                                     during the first 60 days of COBRA coverage, you
Premiums will change on its renewal date of
                                                     must notify your Group within 60 days of
January 1, 2010, unless your Group amends its
                                                     receiving the determination from Social Security.
Agreement and makes changes before its renewal
                                                     Also, if Social Security issues a final
date. Your monthly invoice will reflect current
                                                     determination that you are no longer disabled in
premiums that are due for Cal-COBRA coverage,
                                                     the 35th or 36th month of Group continuation
including any changes. For example, if your

62
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


coverage, your Cal-COBRA coverage will end             You must send us the premium payment by the
the later of: (1) expiration of 36 months after your   due date on the bill to be enrolled in




                                                                                                             Part One − Basic Plan
original COBRA effective date, or (2) the first        Cal-COBRA.
day of the first month following 31 days after
Social Security issued its final determination.        Note: If your Group’s agreement with a health
You must notify us within 30 days after you            plan is terminated, your Group is required to
receive Social Security’s final determination that     provide written notice at least 30 days before the
you are no longer disabled.                            termination date to the persons whose
                                                       Cal-COBRA coverage is terminating. This notice
Cal-COBRA open enrollment or termination               must inform Cal-COBRA beneficiaries that they
of another health plan. If you previously elected      can continue Cal-COBRA coverage by enrolling
Cal-COBRA coverage through another health              in any health benefit plan offered by your Group.
plan available through your Group, you may be          It must also include information about benefits,
eligible to enroll in Kaiser Permanente during         premiums, payment instructions, and enrollment
your Group’s annual open enrollment period, or         forms (including instructions on how to continue
if your Group terminates its agreement with the        Cal-COBRA coverage under the new health
health plan you are enrolled in. You will be           plan). Your Group is required to send this
entitled to Cal-COBRA coverage only for the            information to the person’s last known address,
remainder, if any, of the coverage period              as provided by the prior health plan. Health Plan
prescribed by Cal-COBRA. Please ask your               is not obligated to provide this information to
Group for information about health plans               qualified beneficiaries if your Group fails to
available to you either at open enrollment or if       provide the notice.
your Group terminates a health plan’s agreement,
please contact the CalPERS Office of Employer          Termination for nonpayment of Cal-COBRA
and Member Health Services at P.O. Box                 premiums
942714, Sacramento, CA 94229-2714, fax                 If we do not receive your entire premium
number 916-795-1277, or telephone the CalPERS          payment on or before the last day of the month
Customer Service and Education Division toll           preceding the month of coverage, then coverage
free at 888-CalPERS (888-225-7377).                    for you and all your Dependents will end
                                                       retroactively back to the last day of the month for
To continue your Cal-COBRA coverage with us,           which we received a full premium payment. This
we must receive your enrollment application            retroactive period will not exceed 60 days before
during your Group’s open enrollment period, or         the date we mail you a notice confirming
within 63 days of receiving the termination notice     termination of membership. If we do not receive
described below from your Group. To request an         premium payment on or before the last day of the
application, please call our Member Service Call       month preceding the month of coverage, we will
Center. We will send you our enrollment                send a Notice of Termination (notice of
application and you must return your completed         nonreceipt of payment) to the Subscriber’s
application before open enrollment ends or within      address of record. We will mail this notice at
63 days of receiving the termination notice            least 15 days before any termination of coverage
described below from your Group. If we approve         and it will include the following information:
your enrollment application, we will send you
billing information within 30 days after we            • A statement that we have not received full
receive your application. You must pay the bill          premium payment and that we will terminate
within 45 days after the date we issue the bill.         your membership for nonpayment if we do not


                                                                                                       63
     receive the required premiums within 15 days   elect USERRA coverage and how much you must
     from the date the notice confirming            pay your Group.
     termination of membership was mailed
• The specific date and time when coverage for      Coverage for a disabling condition
  you and all of your Dependents will end if we     If you became totally disabled after December
  do not receive the premiums                       31, 1977, while you were a Member under your
                                                    Group’s Agreement with us and while the
We will terminate your membership if we do not      Subscriber was employed by your Group, and
receive payment within 15 days of the date we       your Group’s Agreement with us terminates,
mailed you the Notice of Termination (notice of     coverage for your disabling condition will
nonreceipt of payment). We will mail a notice       continue until any one of the following events
confirming termination of membership, which         occurs:
will inform you of the following:                   • 12 months have elapsed
• That we have terminated your membership for       • You are no longer disabled
  nonpayment of premiums
                                                    • Your Group’s Agreement with us is replaced
• The specific date and time when coverage for        by another group health plan without
  you and all your Dependents ended                   limitation as to the disabling condition
• Information explaining whether or not you can
  reinstate your membership                         Your coverage will be subject to the terms of this
                                                    DF/EOC including Copayments and
Reinstatement of your membership after              Coinsurance.
termination for nonpayment of premiums. If
we terminate your membership for nonpayment         For Subscribers and adult Dependents, “totally
of premiums, we will permit reinstatement of        disabled” means that, in the judgment of a
your membership twice during any 12-month           Medical Group physician, an illness or injury is
period if we receive the amounts owed within        expected to result in death or has lasted or is
15 days of the date the notice confirming           expected to last for a continuous period of at least
termination of membership was mailed to you.        12 months and makes the person unable to
We will not reinstate your membership if you do     engage in any employment or occupation, even
not obtain reinstatement of your terminated         with training, education, and experience.
membership within the required 15 days, or if we
terminate your membership for nonpayment of         For Dependent children, “totally disabled”
premiums more than twice in a 12-month period.      means that, in the judgment of a Medical Group
                                                    physician, an illness or injury is expected to result
Uniformed Services Employment and                   in death or has lasted or is expected to last for a
Reemployment Rights Act (USERRA)                    continuous period of at least 12 months and the
If you are called to active duty in the uniformed   illness or injury makes the child unable to
services, you may be able to continue your          substantially engage in any of the normal
coverage under this DF/EOC for a limited time       activities of children in good health of like age.
after you would otherwise lose eligibility, if
required by the federal USERRA law. You must        To request continuation of coverage for your
submit a USERRA election form to your Group         disabling condition, you must call our Member
within 60 days after your call to active duty.      Service Call Center within 30 days of the date
Please contact your Group to find out how to        your Group’s Agreement with us terminates.


64
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370), 7 a.m.–7 p.m. weekdays and 7
                                    a.m.–3 p.m. weekends


Leave of Absence                                      in our Individual–Conversion Plan if you no
If you qualify for continuing group membership        longer meet the eligibility requirements described




                                                                                                              Part One − Basic Plan
by completion of HBD Form 21, you should              under “Eligibility” in the “Premiums, Eligibility,
contact your Health Benefits Officer who will         and Enrollment” section. Also, if you enroll in
help you make the necessary changes in your           Group continuation coverage through COBRA,
enrollment while you are on a leave of absence.       Cal-COBRA, or USERRA you may be eligible to
                                                      enroll in our Individual–Conversion Plan when
If you are paying your monthly premiums using         your Group continuation coverage ends. The
the coupon payment book, please send your             premiums and coverage under our Individual–
payment to the following address:                     Conversion Plan are different from those under
                                                      this DF/EOC.
    Kaiser Permanente
    P.O. Box 7004                                     To be eligible for our Individual–Conversion
    Anaheim, CA 92850-7004                            Plan, there must be no lapse in your coverage and
                                                      we must receive your enrollment application
If you receive a billing statement for your           within 63 days of the date of our termination
monthly premiums, please send your payment to         letter or of your membership termination date
the following address:                                (whichever date is later). To request an
    Kaiser Permanente                                 application, please call our Member Service Call
    P.O. Box 7027                                     Center.
    Anaheim, CA 92850-7027
                                                      If we approve your enrollment application, we
Please note that it is very important to make the     will send you billing information within 30 days
necessary enrollment changes and establish your       after we receive your application. You must pay
account before you begin making monthly               the bill within 45 days after the date we issue the
payments. Contact your Health Benefits Officer        bill. Because your coverage under our
to make the necessary enrollment changes prior        Individual–Conversion Plan begins when your
to your leave of absence. If you have additional      Group coverage ends (including Group
questions, please call our Member Service Call        continuation coverage), your first payment to us
Center.                                               will include coverage from when your Group
                                                      coverage ended through our current billing cycle.
Conversion from Group Membership to                   You must send us the premium payment by the
an Individual Plan                                    due date on the bill to be enrolled in our
                                                      Individual–Conversion Plan.
After your Group notifies us to terminate your
membership, we will send a termination letter to      You may not convert to our Individual–
the Subscriber’s address of record. The letter will   Conversion Plan if any of the following is true:
include information about options that may be
available to you to remain a Health Plan member.      • You continue to be eligible for coverage
                                                        through your Group (but not counting
                                                        COBRA, Cal-COBRA, or USERRA coverage)
Kaiser Permanente Conversion Plan
If you want to remain a Health Plan member, one       • Your membership ends because your Group’s
option that may be available is an individual plan      Agreement with us terminates and it is
called “Kaiser Permanente Individual–                   replaced by another plan within 15 days of the
Conversion Plan.” You may be eligible to enroll         termination date


                                                                                                         65
• We terminated your membership under                 • You are not eligible for coverage under a
  “Termination for Cause” in the “Termination           group health plan, Medicare, or Medicaid
  of Membership” section                                (Medi-Cal)
• You live in the service area of a Region            • You have no other health care coverage
  outside California, except that the Subscriber’s    • You have elected and exhausted any
  or the Subscriber’s Spouse’s otherwise-eligible       continuation coverage you were offered under
  children may be eligible to be covered                COBRA or Cal-COBRA
  Dependents even if they live in (or move to)
  the service area of a Region outside California     For more information (including premiums and
  (please refer to the “Eligibility” in the           complete eligibility requirements), please refer to
  “Premiums, Eligibility, and Enrollment”
                                                      the Kaiser Permanente HIPAA Individual Plan
  section for more information)
                                                      evidence of coverage. To request a copy of the
                                                      HIPAA Individual Plan evidence of coverage or
HIPAA and other individual plans                      for information about other individual plans, such
The Health Insurance Portability and                  as Kaiser Permanente for Individuals and
Accountability Act of 1996 (HIPAA) protects           Families plans, please call our Member Service
health care coverage for workers and their            Call Center.
families when they change or lose their jobs. If
you lose group health care coverage and meet
certain criteria, you are entitled to purchase
individual (nongroup) health care coverage from
any health plan that sells individual health care
coverage.

Every health plan that sells individual health care
coverage must offer individual coverage to an
eligible person under HIPAA. The health plan
cannot reject your application if you are an
eligible person under HIPAA, you agree to pay
the required premiums, and you live or work
inside the plan’s service area. To be considered
an eligible person under HIPAA you must meet
the following requirements:
• You have 18 or more months of creditable
  coverage without a break of 63 days or more
  between any of the periods of creditable
  coverage or since the most recent coverage
  was terminated
• Your most recent creditable coverage was
  under a group, government, or church plan
  (COBRA and Cal-COBRA are considered
  group coverage)
• You were not terminated from your most
  recent creditable coverage due to nonpayment
  of premiums or fraud
66
Kaiser Foundation Health Plan, Inc.
Northern and Southern California Regions




PART TWO − DISCLOSURE FORM AND EVIDENCE OF
COVERAGE FOR KAISER PERMANENTE SENIOR ADVANTAGE




                                                                                          Part Two − Senior Advantage
January 1, 2010, through December 31, 2010




                                             Member Service Call Center
                                             Every day 8 a.m.–8 p.m.
                                             800-443-0815 toll free
                                             800-777-1370 (TTY for the
                                                hearing/speech impaired) toll free
                                             kp.org




                                                                                     67
BENEFIT CHANGES FOR CURRENT YEAR

This is your Annual Notice of Change. The following is a summary of the most important changes and
clarifications that we have made to this Kaiser Permanente Senior Advantage 2010 Disclosure Form and
Evidence of Coverage (DF/EOC). Please read this DF/EOC for the complete text of these changes, as well
as changes not listed in the summary below. In addition, please refer to the “Premiums” section for
information about 2010 Premiums.

Please refer to the “Benefits, Copayments, and Coinsurance” section in this DF/EOC for benefit
descriptions and the amount Members must pay for covered benefits. Benefits are also subject to the
“Emergency, Post-Stabilization, and Urgent Care from Non–Plan Providers” and the “Exclusions,
Limitations, Coordination of Benefits, and Reductions” sections in Part Two of this DF/EOC.

Disposable supplies
We are adding an exclusion to Kaiser Permanente Senior Advantage DF/EOC to clarify that we will not
cover disposable supplies other than supplies that Medicare covers. The Non-Medicare DF/EOC already
include an exclusion for disposable supplies.

Hospice care
Hospice care will be covered inside California but within 15 miles or 30 minutes from our Service Area for
Members who have been continuously enrolled in Kaiser Permanente Senior Advantage since before
January 1, 1999 and have lived at the same address since. We are making this change for consistency with
non-Medicare DF/EOCs. Previously, these Members had coverage for hospice care only within our Service
Area.

Kaiser Permanente Senior Advantage DF/EOCs
We are making the following changes for consistency with the standard wording for Medicare DF/EOCs
provided by the Centers for Medicare & Medicaid Services (CMS):
• We are revising the “Requests for Payment” and “Dispute Resolution” sections. The information
  contained in the two sections is now described in the “Emergency, Post-Stabilization, and Urgent Care
  from Non–Plan Providers,” “Grievances,” and “Requests for Services or Payment, Complaints, and
  Medicare Appeal Procedures” sections
• We are moving important contact information into a new section called “Helpful Phone Numbers and
  Resources”

We have also revised Kaiser Permanente Senior Advantage DF/EOCs to clarify that we cover physical,
occupational, and speech therapy, and multidisciplinary rehabilitation in accord with Medicare guidelines,
instead of including Medicare coverage guidelines in the DF/EOC. Also, we have moved the description of
coverage for these Services into the “Outpatient Care,” “Hospital Inpatient Care,” “Hospice Care,” and
“Skilled Nursing Facility Care” sections. Previously, coverage was described under a separate heading in
the “Benefits, Copayments, and Coinsurance” section.

Keeping track of the annual out-of-pocket maximum
We have removed this paragraph because Senior Advantage members no longer have to keep track of the
annual out-of-pocket maximum by keeping the receipts and calling our Member Service Call Center. We
will begin tracking this information for you and will inform you when you don't have to pay any more


68
Copayments or Coinsurance for the remainder of the calendar year for Services that are subject to the
annual out-of-pocket maximum.

Prescription Drugs
Effective January 1, 2010, the amount you must pay to reach catastrophic coverage level for Medicare Part
D drugs, will increase from $4,350 to $4,550. Each year effective on January 1, CMS may change this
amount and the catastrophic coverage level that apply for the calendar year. We will notify you in advance
of any change to your coverage
• Medicare provides “extra help” to pay prescription drug costs for people who have limited income and
  resources. If you qualify, you may get help paying for contributions you make toward your Group’s
  Medicare Part D premium and your Part D prescription drug Copayments may be lower as described in
  Evidence of Coverage Rider for those who Receive Extra Help Paying for their Prescription Drugs,
  which you will receive before October 31, 2009
• We have clarified that the vaccines (immunizations) administered in a Plan Medical Office that are no




                                                                                                               Part Two − Senior Advantage
  charge are those that are covered by Medicare Part B

You will receive a Pharmacy Directory and new Medicare Part D Formulary by October 31, 2009 that will
be effective January 1, 2010. When you receive the formulary, please review it to see if we still cover the
drugs that you currently take. If a drug we currently cover for you is not on our new formulary, you will
need to talk to your doctor about taking an alternative drug that is available on our new formulary. If you
wish to continue coverage of your current drug, you or your doctor can request a formulary exception on or
after January 1. Beginning January 1, you will get a temporary supply of the drug we currently cover for
you that is not on our new formulary. You will need to talk to your doctor about switching to a covered
drug, or request a formulary exception before your temporary supply runs out. The formulary will include
instructions on how to file an exception.

Physical exam
For Kaiser Permanente Senior Advantage Members, the “Welcome to Medicare” physical exam will be
covered within the first 12 months after enrollment in Medicare Part B in accord with Medicare guidelines.
Previously it was covered within the first 6 months after enrollment in Medicare Part B.

Services that apply towards the annual out-of-pocket maximum
We have revised the list of services that apply to the annual out-of-pocket maximum. For example,
Medicare Part B drugs will now apply to the annual out-of-pocket maximum.




                                                                                                          69
KAISER PERMANENTE SENIOR ADVANTAGE BENEFIT
SUMMARY

Service                                                   You Pay
Professional Services (Plan Provider office visits)
Routine preventive care:
   Physical exams                                         $10 per visit
   Family planning visits                                 $10 per visit
   Scheduled prenatal care and first postpartum visit     $10 per visit
   Eye refraction exams and glaucoma screening            $10 per visit
   Hearing tests                                          $10 per visit
   Primary and specialty care visits                      $10 per visit
Urgent care visits                                        $10 per visit
Physical, occupational, and speech therapy                $10 per visit
Biofeedback                                               $10 per visit
Acupuncture when performed by a Plan Physician            $10 per visit
Outpatient Services
Outpatient surgery and certain other outpatient
procedures                                                $10 per procedure
Allergy injection visits                                  $3 per visit
Allergy testing visits                                    $10 per visit
X-rays and lab tests                                      No charge
Health education:
Individual visits                                         $10 per visit
   Group educational programs                             No charge
Hospitalization Services
Room and board, surgery, anesthesia, X-rays, lab tests,
and drugs                                                 No charge
Emergency Care
Emergency Department visits                               $50 for Emergency Department visits
                                                          (does not apply if you are held for observation
                                                          in a hospital unit outside the Emergency
                                                          Department or if admitted directly to the
                                                          hospital as an inpatient)
Ambulance Services
Ambulance Services                                        No charge
Prescription Drug Coverage
Most covered outpatient items in accord with our drug
formulary guidelines from Plan Pharmacies or from our
mail-order service:
Generic items                                             $5 generic for up to a 100 day supply
Brand-name items                                          $15 brand-name for up to a 100 day supply
Durable Medical Equipment (DME)
Covered DME for home use in accord with our DME
formulary and Medicare guidelines                         No charge


70
Service                                                     You Pay
Mental Health Services
Inpatient psychiatric hospitalization                       No charge
Outpatient visits:
Individual and group visits                                 $10 per individual visit
                                                            $5 per group visit
Chemical Dependency Services
Inpatient detoxification                                    No charge
Outpatient individual visits                                $10 per visit
Outpatient group visits                                     $5 per visit
Home Health Services
Home health care                                            No charge
Chiropractic Care
Chiropractic visits                                         $10 per visit (up to 20 visits per calendar year)




                                                                                                                 Part Two − Senior Advantage
Other
Hearing aid (s)                                             $1,000 Allowance (every 36 months)
Skilled Nursing Facility care (up to 100 days per benefit
period)                                                     No charge
Prosthetic and orthotic devices or ostomy and urological
supplies in accord with Medicare guidelines                 No charge
All covered Services related to infertility treatment       $10 per visit
Hospice care for Members without Medicare Part A            No charge
Eyeglasses and contact lenses (every 24 months)             $175 Allowance
Eyeglasses and contact lenses following cataract surgery    $150 Allowance

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,
Copayments and Coinsurance, out-of-pocket maximums, exclusions, or limitations, nor does it list all
benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the “Benefits,
Copayments, and Coinsurance” and “Exclusions, Limitations, Coordination of Benefits, and Reductions”
sections.




                                                                                                            71
INTRODUCTION

Kaiser Foundation Health Plan, Inc. (Health Plan)    in Part Three of this DF/EOC. The coverage
has a contract with the Centers for Medicare &       information in this DF/EOC applies when you
Medicaid Services (CMS) as a Medicare                obtain care in your Home Region. When you visit
Advantage Organization, which is renewed             the other California Region, you may receive care
annually. This contract provides Medicare            as described in “Visiting Other Regions” in the
Services (including Medicare Part D prescription     “How to Obtain Services” section.
drug coverage) through “Kaiser Permanente
Senior Advantage with Part D” (“Senior               Please read the following information so that
Advantage” or “Managed Medicare Health               you will know from whom or what group of
Plan”), except for hospice care for Members with     providers you may get health care. It is
Medicare Part A and qualifying clinical trials,      important to familiarize yourself with your
which are covered under Original Medicare.           coverage by reading Parts Two and Three of this
                                                     DF/EOC completely, so that you can take full
Senior Advantage is for Members entitled to          advantage of your Health Plan benefits. Also, if
Medicare, providing the advantages of combined       you have special health care needs, please
Medicare and Health Plan benefits. Enrollment in     carefully read the sections that apply to you.
this Senior Advantage plan means that you are
automatically enrolled in Medicare Part D.           Term of this DF/EOC
                                                     This DF/EOC is for the period January 1, 2010,
Part Two and Part Three of this Disclosure Form      through December 31, 2010, unless amended.
and Evidence of Coverage (DF/EOC) describes          Your Health Benefits Officer (or, if you are
our Senior Advantage health care coverage of the     retired, the CalPERS Office of Employer and
“Managed Medicare Health Plan” provided under        Member Health Services) can tell you whether
the Group Agreement (Agreement) between              this DF/EOC is still in effect and give you a
Health Plan (Kaiser Foundation Health Plan, Inc.,    current one if this DF/EOC has expired or been
Northern California Region and Southern              amended.
California Region) and your Group (CalPERS).
For benefits provided under any other Health         About Kaiser Permanente
Plan program, refer to that plan’s evidence of
coverage.                                            Kaiser Permanente provides Services directly to
                                                     our Members through an integrated medical care
In this DF/EOC, Health Plan is sometimes             program. Health Plan, Plan Hospitals, and the
referred to as “we” or “us.” Members are             Medical Group work together to provide our
sometimes referred to as “you.” Some capitalized     Members with quality care. Our medical care
terms have special meaning in this DF/EOC;           program gives you access to all of the covered
please see the “Definitions” section in Part Three   Services you may need, such as routine care with
of this DF/EOC for terms you should know.            your own personal Plan Physician, hospital care,
                                                     laboratory and pharmacy Services, Emergency
When you join Kaiser Permanente, you are             Care, Urgent Care, and other benefits described
enrolling in one of two Health Plan Regions in       in the “Benefits, Copayments, and Coinsurance”
California (either our Northern California Region    section. Plus, our healthy living (health
or Southern California Region), which we call        education) programs offer you great ways to
your “Home Region.” The Service Area of each         protect and improve your health. For preventive
Region is described in the “Definitions” section     screening tests and vaccines that Plan Physicians
72
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


recommend for generally healthy people, please      • Emergency ambulance Services as described
refer to “Preventive Screenings and Vaccines” in      under “Ambulance Services” in the “Benefits,
the appendix to this DF/EOC. For more                 Copayments, and Coinsurance” section
information about preventive care guidelines, as    • Emergency Care, Post-Stabilization Care, and
well as recommended lifestyle practices, please       Urgent Care as described in the “Emergency,
refer to Your Guidebook to Kaiser Permanente          Post-Stabilization, and Urgent Care from Non–
Services, or visit our Web site at kp.org.            Plan Providers” section

We provide covered Services to Members using        • Home health care as described under “Home
Plan Providers located in your Home Region’s          Health Care” in the “Benefits, Copayments,
Service Area, which is described in the               and Coinsurance” section
“Definitions” section in Part Three of this         • Ostomy and urological supplies as described
DF/EOC. You must receive all covered care from        under “Ostomy and Urological Supplies” in
Plan Providers inside your Home Region’s              the “Benefits, Copayments, and Coinsurance”




                                                                                                       Part Two − Senior Advantage
Service Area, except as described in the sections     section
listed below for the following Services:            • Out-of-area dialysis care as described under
• Authorized referrals as described under             “Dialysis Care” in the “Benefits, Copayments,
  “Getting a Referral” in the “How to Obtain          and Coinsurance” section
  Services” section                                 • Prescription drugs from Non–Plan Pharmacies
• Chiropractic services as described in the “ASH      as described under “Outpatient Prescription
  Plans Chiropractic Services” section in Part        Drugs, Supplies, and Supplements” in the
  Two of this DF/EOC, and for Southern                “Benefits, Copayments, and Coinsurance”
  California Region Members, chiropractic             section
  services as described under “Chiropractic         • Prosthetic and orthotic devices as described
  Services” in the “Benefits, Copayments, and         under “Prosthetic and Orthotic Devices” in the
  Coinsurance” section                                “Benefits, Copayments, and Coinsurance”
• Durable medical equipment as described under        section
  “Durable Medical Equipment for Home Use”          • Visiting member care as described under
  in the “Benefits, Copayments, and                   “Visiting Other Regions” in the “How to
  Coinsurance” section                                Obtain Services” section




                                                                                                  73
PREMIUMS, ELIGIBILITY, AND ENROLLMENT

Premiums                                               CalPERS Office of Employer and Member
                                                       Health Services).
Your Group is responsible for paying Premiums.
If you are responsible for any contribution to the
                                                       Medicare Part D late enrollment penalty.
Premiums, your Group will tell you the amount
and how to pay your Group. In addition to any          If you don't join a Medicare Part D drug plan
amount you must pay your Group, you must also          when you are first eligible, or you go without
continue to pay Medicare your monthly Medicare         creditable prescription drug coverage for a
premium.                                               continuous period of 63 days or more, you may
                                                       have to pay a late enrollment penalty when you
 California Residents        Monthly Premiums          enroll in a Part D plan later (this DF/EOC is a
 Self only                   $298.36                   Part D plan). Your Group will inform you if the
 Self and one Dependent      $596.72                   penalty applies to you. However, if you qualify
                                                       for extra help, you may not have to pay a penalty.
 Self and two or more        $895.08
 Dependents
                                                       If you disagree with your late enrollment penalty,
                                                       you may be eligible to have it reconsidered
 Out of State                Monthly Premiums
                                                       (reviewed). Call our Member Service Call Center
 Self only                   $319.34
                                                       to find out more about the late enrollment penalty
 Self and one Dependent      $638.68                   reconsideration process and how to ask for such a
 Self and two or more        $958.02                   review. You can also visit www.medicare.gov on
 Dependents                                            the web or call 800-MEDICARE/800-633-4227
                                                       (TTY users call 877-486-2048) 24 hours a days,
Your contribution                                      seven days a week, for more information.
State annuitants. The Premiums listed above
will be reduced by the amount the state of             Extra help with drug plan expenses
California or your contracting agency contributes      Medicare provides “extra help” to pay
toward the cost of your health benefit plan. These     prescription drug costs for people who have
contribution amounts are subject to change as a        limited income and resources. Resources include
result of legislative action. Any such change will     your savings and stocks, but not your home or
be accomplished by the affected retirement             car. If you qualify, you may get help paying for
system without any action on your part. For            any Medicare drug plan's monthly premium, and
current contribution information, contact your         prescription Copayments. If you qualify, this
Health Benefits Officer (or, if you are retired, the   extra help will count toward your out-of-pocket
CalPERS Office of Employer and Member                  costs.
Health Services).
                                                       People with limited income and resources may
Contracting agency annuitants. The Premiums            qualify for extra help one of two ways. The
listed above will be reduced by the amount your        amount of extra help you get will depend on your
contracting agency contributes toward the cost of      income and resources.
your health benefit plan. This amount varies
among contracting agencies. For assistance on          • You automatically qualify for extra help
calculating your net contribution, contact your          and don't need to apply. If you have full
Health Benefits Officer (or, if you are retired, the     coverage from a state Medicaid program, get
                                                         help from Medicaid paying your Medicare
74
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  premiums (belong to a Medicare Savings              please contact our Member Service Call Center.
  Program), or get Supplemental Security              The evidence is often a letter from either your
  Income benefits, you automatically qualify for      state Medicaid or Social Security office that
  extra help and do not have to apply for it.         states you are qualified for extra help. You will
  Medicare notifies people who automatically          need to provide the evidence to a Plan Pharmacy
  qualify for extra help                              when you obtain prescriptions so that we can
• You apply and qualify for extra help. You           charge you the appropriate Copayments, or
  may qualify if your yearly income in 2009 is        Coinsurance amount until the Centers for
  less than $16,245 (single with no dependents)       Medicare & Medicaid Services (CMS) updates its
  or $21,855 (married and living with your            records to reflect your current status. Once CMS
  spouse with no dependents), and your                updates its records, you will no longer need to
  resources are less than $12,510 (single) or         present the evidence to a Plan Pharmacy. In order
  $25,010 (married and living with your spouse).      for CMS to update its records, you must send
  These resource amounts include $1,500 per           your evidence to one of the following locations




                                                                                                           Part Two − Senior Advantage
  person for burial expenses. Resources include       and we will forward your evidence to CMS for
  your savings and stocks but not your home or        updating:
  car. (The income amounts are for 2009 and                Kaiser Foundation Health Plan, Inc.
  will change in 2010.) If you think you may               California Service Center
  qualify, call Social Security toll free at               Attn: Best Available Evidence
  800-772-1213 (TTY users call 800-325-0778)               P.O. Box 232407
  or visit www.socialsecurity.gov on the Web.              San Diego, CA 92193-2407
  You may also be able to apply at your State              Fax it toll free to 866-311-0514
  Medical Assistance (Medicaid) office. After
  you apply, you will get a letter in the mail        Bring it to a Plan Pharmacy or Member Services
  letting you know if you qualify and what you        office at a Plan Facility listed in Your Guidebook
  need to do next                                     to Kaiser Permanente Services

If you qualify for extra help, we will send you an    Please be assured that if you overpay your
Evidence of Coverage Rider for those who              Copayment, we will reimburse you. Either we
Receive Extra Help Paying for their Prescription      will forward a check to you in the amount of your
Drugs that explains your costs as a member of         overpayment or we will offset future
our Plan. If the amount of your extra help            Copayments. If a state paid on your behalf, we
changes during the year, we will also mail you an     may make payment directly to the state. Please
updated Evidence of Coverage Rider for those          contact our Member Service Call Center if you
who Receive Extra Help Paying for their               have questions.
Prescription Drugs.
                                                      Eligibility
If you believe you have qualified for extra help      To enroll and to continue enrollment, you must
and you believe that you are paying an incorrect      meet all of the eligibility requirements described
Copayment amount when you get your                    in this “Eligibility” section. The CalPERS Health
prescription at a Plan Pharmacy, we have              Program enrollment and eligibility requirements
established a process that will allow you to either   are determined in accord with the Public
request assistance in obtaining evidence of your      Employees’ Medical & Hospital Care Act
proper Copayment level, or, if you already have       (PEMHCA), the Social Security Administration
the evidence, to provide this evidence to us. If      (SSA), and the Centers for Medicare & Medicaid
you aren't sure what evidence to provide us,

                                                                                                      75
Services (CMS). For an explanation of specific        • You may enroll in Senior Advantage
enrollment and eligibility criteria, please consult     regardless of health status, except that you
your Health Benefits Officer (or, if you are            may not enroll if you have end-stage renal
retired, the CalPERS Office of Employer and             disease. This restriction does not apply to you
Member Health Services).                                if you are currently a Health Plan Member in
                                                        the Northern California or Southern California
Under the Public Employees’ Medical & Hospital          Region and you developed end-stage renal
Care Act (PEMHCA), if you are Medicare-                 disease while a Member
eligible and do not enroll in Medicare Parts A and    • You may not be able to enroll if Senior
B and in a CalPERS Medicare health plan, you            Advantage has reached a capacity limit that the
and your enrolled Dependents will be excluded           Centers for Medicare & Medicaid Services has
from coverage under the CalPERS program. If             approved. This limitation does not apply if you
you are eligible and enrolled in Medicare Part B,       are currently a Health Plan Member in the
but are not eligible for Medicare Part A without        Northern California or Southern California
cost, you will not be required to enroll in a           Region who is eligible for Medicare (for
CalPERS Medicare health plan; however, you are          example, when you turn age 65)
still eligible to enroll in Kaiser Permanente
Senior Advantage.                                     Note: You may not be enrolled in two Medicare-
                                                      health plans at the same time. If you enroll in
Information pertaining to eligibility, enrollment,    Senior Advantage, CMS will automatically
termination of coverage, and conversion rights        disenroll you from any other Medicare-health
can be obtained through the CalPERS Web site at       plan, including a Medicare Prescription Drug
www.calpers.ca.gov or by calling CalPERS.             Plan.
Also, please refer to the CalPERS Health
Program Guide for information about eligibility.      Service Area eligibility requirements
                                                      You (the Subscriber) must live in your Home
It is your responsibility to stay informed about
                                                      Region’s Service Area unless if you have been
your coverage. If you have any questions, contact
                                                      continuously enrolled in Senior Advantage since
your:
                                                      December 31, 1998, and lived outside your Home
• Health Benefits Officer in your agency              Region’s Service Area during that time. In which
• If you are retired, the CalPERS Office of           case, you may continue your membership unless
  Employer and Member Health Services, P.O.           you move and are still outside your Home
  Box 942714, Sacramento, CA 94229-2714.              Region’s Service Area. The “Service Area”
  Fax number: 916-795-1277                            section in Part Three of this DF/EOC describes
                                                      your Home Region’s Service Area and how it
• CalPERS Customer Service and Education
                                                      may change.
  Division toll free at 888-CalPERS
  (888-225-7377) TTY users call 800-735-2929
                                                      Moving from your Home Region’s Service
  or 916-795-3240
                                                      Area to our other California Region’s Service
                                                      Area. You must complete a new Senior
Medicare eligibility requirements                     Advantage Election Form to continue Senior
• You must be entitled to benefits under              Advantage coverage, if you move from your
  Medicare Parts A and B or Part B only               Home Region’s Service Area to the Service Area
                                                      of our other California Region (the Service Area
• Your Medicare coverage is primary
                                                      of both Regions are described in the “Service

76
       Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Area” section). To get a Senior Advantage             • Durable medical equipment as described under
Election Form, please call our Member Service           “Durable Medical Equipment for Home Use”
Call Center toll free at 800-443-0815 (TTY users        in the “Benefits, Copayments, and
call 800-777-1370) every day 8 a.m. to 8 p.m.           Coinsurance” section
                                                      • Emergency ambulance Services as described
Moving outside our Northern and Southern                under “Ambulance Services” in the “Benefits,
California Regions’ Service Areas. If you               Copayments, and Coinsurance” section
permanently move outside our Northern and
Southern California Regions’ Service Areas, or        • Emergency Care, Post-Stabilization Care, and
you are temporarily absent from your Home               Out-of-Area Urgent Care as described in the
Region’s Service Area for a period of more than         “Emergency, Post-Stabilization, and Urgent
six months in a row, you must notify us and you         Care from Non–Plan Providers” section
cannot continue your Senior Advantage                 • Home health care as described under “Home
membership under this DF/EOC.                           Health Care” in the “Benefits, Copayments,




                                                                                                           Part Two − Senior Advantage
                                                        and Coinsurance” section
Send your notice to:                                  • Ostomy and urological supplies as described
   For Northern California Members:                     under “Ostomy and Urological Supplies” in
   Kaiser Foundation Health Plan, Inc.                  the “Benefits, Copayments, and Coinsurance”
   California Service Center                            section
   P.O. Box 232400
                                                      • Out-of-area dialysis care as described under
   San Diego, CA 92193
                                                        “Dialysis Care” in the “Benefits, Copayments,
                                                        and Coinsurance” section
    For Southern California Members:
    Kaiser Foundation Health Plan, Inc.               • Prescription drugs from Non–Plan Pharmacies
    California Service Center                           as described under “Outpatient Prescription
    P.O. Box 232407                                     Drugs, Supplies, and Supplements” in the
    San Diego, CA 92193                                 “Benefits, Copayments, and Coinsurance”
                                                        section
It is in your best interest to notify us as soon as   • Prosthetic and orthotic devices as described
possible because until your Senior Advantage            under “Prosthetic and Orthotic Devices” in the
coverage is officially terminated by CMS, you           “Benefits, Copayments, and Coinsurance”
will not be covered by us or Original Medicare          section
for any care received from Non–Plan Providers,
                                                      • Visiting member care as described under
except as described in the sections listed below        “Visiting Other Regions” in the “How to
for the following Services:                             Obtain Services” section
• Authorized referrals as described under
  “Getting a Referral” in the “How to Obtain          Regions outside California. If you move to the
  Services” section                                   service area of another Region outside California,
• Chiropractic services as described in the “ASH      please contact the Health Benefits Officer in your
  Plans Chiropractic Services” section in Part        agency (or, if you are retired, the CalPERS Office
  Two of this DF/EOC, and for Southern                of Employer and Member Health Services) to
  California Region Members, chiropractic             learn about your Group health care options. You
  services as described under “Chiropractic           may be able to enroll in the new service area if
  Services” in the “Benefits, Copayments, and         there is an agreement between CalPERS and that
  Coinsurance” section                                Region, but the plan, including coverage,


                                                                                                     77
premiums, and eligibility requirements, might not    entitled to Medicare Part B, we will notify you of
be the same.                                         your effective date. Your effective date will
                                                     generally be determined by the date we receive
Please call our Member Service Call Center for       your completed Election Form and the effective
more information about our other Regions,            date of your Group coverage.
including their locations in the District of
Columbia and parts of Colorado, Georgia,             Once CMS confirms your enrollment, we will
Hawaii, Idaho, Maryland, Ohio, Oregon,               send you written notification. If CMS does not
Virginia, and Washington.                            confirm your enrollment in Medicare before your
                                                     effective date, you still must receive your care
Note: You may be able to receive certain care if     from us, beginning on your effective date, just as
you are visiting a service area in another Region.   if your enrollment had been confirmed. If CMS
See “Visiting Other Regions” in the “How to          tells us that you are not entitled to Medicare Part
Obtain Services” section for information.            B, we will notify you and request that you contact
                                                     the Social Security Administration to clarify your
Enrollment                                           Medicare status. If, after contacting the Social
                                                     Security Administration, it is confirmed that you
Information pertaining to enrollment can be
                                                     are still not entitled to Medicare Part B, you will
found in the CalPERS Health Program Guide,
                                                     be billed for any Services we have provided you
which is available from the CalPERS Web site at
                                                     unless you are an existing Member under another
www.calpers.ca.gov or by calling CalPERS.
                                                     Kaiser Permanente plan (for example, the Basic
                                                     Plan). Members will be responsible for any
If you are already a Health Plan Member who
                                                     amounts owed under their other Kaiser
lives in the Senior Advantage Service Area, we
                                                     Permanente plan and should contact their Health
will mail you information on how to join Senior
                                                     Benefits Officer (or, if you are retired, the
Advantage and a Senior Advantage Election
                                                     CalPERS Office of Employer and Member
Form shortly before you reach age 65.
                                                     Health Services) for details.
Effective date of Senior Advantage coverage
                                                     Group open enrollment
After we receive your completed Senior
Advantage Election Form, we will submit your         You may enroll as a Subscriber (along with any
enrollment to CMS and send you a notice              eligible Dependents), and existing Subscribers
indicating the proposed effective date of your       may add eligible Dependents, by submitting a
Senior Advantage coverage, which is subject to       Health Plan–approved enrollment application and
confirmation by CMS. Your effective date will        a Senior Advantage Election Form (one form for
depend on whether you are first becoming             each Medicare beneficiary) to your Group during
entitled to Medicare Part B, or if you are already   your Group’s open enrollment period. Your
entitled to it.                                      Group will let you know when the open
                                                     enrollment period begins and ends and the
If you will soon become entitled to Medicare Part    effective date of coverage.
B, your Senior Advantage effective date will be
the first day of the month in which you are
entitled to Medicare Part B. If you are already




78
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


HOW TO OBTAIN SERVICES

As a Member, you are selecting our medical care       “Benefits, Copayments, and Coinsurance”
program to provide your health care. You must         section
receive all covered care from Plan Providers        • Prosthetic and orthotic devices as described
inside your Home Region’s Service Area, except        under “Prosthetic and Orthotic Devices” in the
as described in the sections listed below for the     “Benefits, Copayments, and Coinsurance”
following Services:                                   section
• Authorized referrals as described under           • Visiting member care as described under
  “Getting a Referral” in this “How to Obtain         “Visiting Other Regions” in the “How to
  Services” section                                   Obtain Services” section
• Chiropractic services as described in the “ASH




                                                                                                         Part Two − Senior Advantage
  Plans Chiropractic Services” section in Part      As a Member, you are enrolled in one of two
  Two of this DF/EOC, and for Southern              Health Plan Regions in California (either our
  California Region Members, chiropractic           Northern California Region or Southern
  services as described under “Chiropractic         California Region), called your Home Region.
  Services” in the “Benefits, Copayments, and       The coverage information in this DF/EOC
  Coinsurance” section                              applies when you obtain care in your Home
• Durable medical equipment as described under      Region.
  “Durable Medical Equipment for Home Use”
  in the “Benefits, Copayments, and                 Our medical care program gives you access to all
  Coinsurance” section                              of the covered Services you may need, such as
                                                    routine care with your own personal Plan
• Emergency ambulance Services as described         Physician, hospital care, laboratory and pharmacy
  under “Ambulance Services” in the “Benefits,
                                                    Services, Emergency Care, Urgent Care, and
  Copayments, and Coinsurance” section
                                                    other benefits described in the “Benefits,
• Emergency Care, Post-Stabilization Care, and      Copayments, and Coinsurance” section.
  Out-of-Area Urgent Care as described in the
  “Emergency, Post-Stabilization, and Urgent        Routine Care
  Care from Non–Plan Providers” section
                                                    If you need to make a routine care appointment,
• Home health care as described under “Home         please refer to Your Guidebook to Kaiser
  Health Care” in the “Benefits, Copayments,        Permanente Services (Your Guidebook) for
  and Coinsurance” section                          appointment telephone numbers, or go to our
• Ostomy and urological supplies as described       Web site at kp.org to request an appointment
  under “Ostomy and Urological Supplies” in         online. Routine appointments are for medical
  the “Benefits, Copayments, and Coinsurance”       needs that aren’t urgent (such as routine
  section                                           preventive care and school physicals). Try to
• Out-of-area dialysis care as described under      make your routine care appointments as far in
  “Dialysis Care” in the “Benefits, Copayments,     advance as possible.
  and Coinsurance” section
                                                    Urgent Care
• Prescription drugs from Non–Plan Pharmacies
  as described under “Outpatient Prescription       When you are sick or injured, you may have an
  Drugs, Supplies, and Supplements” in the          Urgent Care need. An Urgent Care need is one
                                                    that requires prompt medical attention, but is not

                                                                                                    79
an Emergency Medical Condition. If you think        Some specialists who are not designated as
you may need Urgent Care, call the appropriate      Primary Care Physicians but who also provide
appointment or advice nurse telephone number at     primary care may be available as personal Plan
a Plan Facility. Please refer to Your Guidebook     Physicians. For example, some specialists in
for advice nurse and Plan Facility telephone        internal medicine and obstetrics/gynecology who
numbers.                                            are not designated as Primary Care Physicians
                                                    may be available as personal Plan Physicians.
For information about Urgent Care from
Non–Plan Providers, please refer to the             To learn how to select a personal Plan Physician,
“Emergency, Post-Stabilization, and Urgent          please refer to Your Guidebook or call our
Care from Non–Plan Providers” section.              Member Service Call Center.

Our Advice Nurses                                   You can find a directory of our Plan Physicians
                                                    on our Web site at kp.org. For the current list of
We know that sometimes it’s difficult to know
                                                    physicians that are available as Primary Care
what type of care you need. That’s why we have
                                                    Physicians, please call the personal physician
telephone advice nurses available to assist you.
                                                    selection department at the phone number listed
Our advice nurses are registered nurses (RNs)
                                                    in Your Guidebook. You can change your
specially trained to help assess medical
                                                    personal Plan Physician for any reason.
symptoms and provide advice over the phone,
when medically appropriate. Whether you are
calling for advice or to make an appointment, you
                                                    Getting a Referral
can speak to an advice nurse. They can often        Referrals to Plan Providers
answer questions about a minor concern, tell you    A Plan Physician must refer you before you can
what to do if a Plan Medical Office is closed, or   receive care from specialists, such as specialists
advise you about what to do next, including         in surgery, orthopedics, cardiology, oncology,
making a same-day Urgent Care appointment for       urology, and dermatology. However, you do not
you if it’s medically appropriate. To reach an      need a referral to receive care from any of the
advice nurse, please refer to Your Guidebook for    following:
the telephone numbers.
                                                    • Your personal Plan Physician
Your Personal Plan Physician                        • Generalists in internal medicine, pediatrics,
                                                      and family practice
Personal Plan Physicians provide primary care
and play an important role in coordinating care,    • Specialists in optometry, psychiatry, chemical
including hospital stays and referrals to             dependency, and obstetrics/gynecology
specialists.
                                                    Medical Group authorization procedure for
We encourage you to choose a personal Plan          certain referrals
Physician. You may choose any available             The following Services require prior
personal Plan Physician. Most personal Plan         authorization by the Medical Group for the
Physicians are Primary Care Physicians              Services to be covered (prior authorization means
(generalists in internal medicine, pediatrics, or   that the Medical Group must approve the
family practice, or specialists in                  Services in advance for the Services to be
obstetrics/gynecology who the Medical Group         covered):
designates as Primary Care Physicians).             • Durable medical equipment (DME). If your
                                                      Plan Physician prescribes a DME item, he or
80
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  she will submit a written referral to the Plan       Medical Group designee will authorize the
  Hospital’s DME coordinator, who will                 Services if he or she determines that they are
  authorize the DME item if he or she                  Medically Necessary and are not available
  determines that your DME coverage includes           from a Plan Provider. Referrals to Non–Plan
  the item and that the item is listed on our          Physicians will be for a specific treatment
  formulary for your condition. If the item            plan, which may include a standing referral if
  doesn’t appear to meet our DME formulary             ongoing care is prescribed. Please ask your
  guidelines, then the DME coordinator will            Plan Physician what Services have been
  contact the Plan Physician for additional            authorized
  information. If the DME request still doesn’t      • Transplants. If your Plan Physician makes a
  appear to meet our DME formulary guidelines,         written referral for a transplant, the Medical
  it will be submitted to the Medical Group’s          Group’s regional transplant advisory
  designee Plan Physician, who will authorize          committee or board (if one exists) will
  the item if he or she determines that it is          authorize the Services if it determines that they




                                                                                                           Part Two − Senior Advantage
  Medically Necessary. For more information            are Medically Necessary. In cases where no
  about our DME formulary, please refer to             transplant committee or board exists, the
  “Durable Medical Equipment for Home Use”             Medical Group will refer you to physician(s)
  in the “Benefits, Copayments, and                    at a transplant center, and the Medical Group
  Coinsurance” section                                 will authorize the Services if the transplant
• Ostomy and urological supplies. If your Plan         center’s physician(s) determine that they are
  Physician prescribes ostomy or urological            Medically Necessary. Note: A Plan Physician
  supplies, he or she will submit a written            may provide or authorize a corneal transplant
  referral to the Plan Hospital’s designated           without using this Medical Group transplant
  coordinator, who will authorize the item if he       authorization procedure
  or she determines that it is covered and the
  item is listed on our soft goods formulary for     Decisions regarding requests for authorization
  your condition. If the item doesn’t appear to      will be made only by licensed physicians or other
  meet our soft goods formulary guidelines, then     appropriately licensed medical professionals.
  the coordinator will contact the Plan Physician
  for additional information. If the request still   Medical Group’s decision time frames. The
  doesn’t appear to meet our soft goods              applicable Medical Group designee will make the
  formulary guidelines, it will be submitted to      authorization decision within the time frame
  the Medical Group’s designee Plan Physician,       appropriate for your condition, but no later than
  who will authorize the item if he or she           five business days after receiving all the
  determines that it is Medically Necessary. For     information (including additional examination
  more information about our soft goods              and test results) reasonably necessary to make the
  formulary, please refer to “Ostomy and             decision, except that decisions about urgent
  Urological Supplies” in the “Benefits,             Services will be made no later than 72 hours after
  Copayments, and Coinsurance” section               receipt of the information reasonably necessary to
• Services not available from Plan Providers.        make the decision. If the Medical Group needs
  If your Plan Physician decides that you require    more time to make the decision because it doesn’t
  covered Services not available from Plan           have information reasonably necessary to make
  Providers, he or she will recommend to the         the decision, or because it has requested
  Medical Group that you be referred to a Non–       consultation by a particular specialist, you and
  Plan Provider inside or outside your Home          your treating physician will be informed about
  Region’s Service Area. The appropriate             the additional information, testing, or specialist

                                                                                                     81
that are needed, and the date that the Medical        appropriately qualified medical professional. This
Group expects to make a decision.                     is a physician who is acting within his or her
                                                      scope of practice and who possesses a clinical
Your treating physician will be informed of the       background related to the illness or condition
decision within 24 hours after the decision is        associated with the request for a second medical
made. If the Services are authorized, your            opinion.
physician will be informed of the scope of the
authorized Services. If the Medical Group does        Here are some examples of when a second
not authorize all of the Services, you will be sent   opinion is Medically Necessary:
a written decision and explanation within two         • Your Plan Physician has recommended a
business days after the decision is made. The           procedure and you are unsure about whether
letter will include information about your appeal       the procedure is reasonable or necessary
rights, which are described in the “Requests for
Services or Payment, Complaints, and Medicare         • You question a diagnosis or plan of care for a
Appeal Procedures” section. Any written criteria        condition that threatens substantial impairment
that the Medical Group uses to make the decision        or loss of life, limb, or bodily functions
to authorize, modify, delay, or deny the request      • The clinical indications are not clear or are
for authorization will be made available to you         complex and confusing
upon request.                                         • A diagnosis is in doubt due to conflicting test
                                                        results
Copayments and Coinsurance. The
                                                      • The Plan Physician is unable to diagnose the
Copayments and Coinsurance for these referral
                                                        condition
Services are the Copayments and Coinsurance
required for Services provided by a Plan Provider     • The treatment plan in progress is not
as described in the “Benefits, Copayments, and          improving your medical condition within an
Coinsurance” section.                                   appropriate period of time, given the diagnosis
                                                        and plan of care
More information. This description is only a          • You have concerns about the diagnosis or plan
brief summary of the authorization procedure.           of care
The policies and procedures (including a
description of the authorization procedure or         You can either ask your Plan Physician to help
information about the authorization procedure         you arrange for a second medical opinion, or you
applicable to some Plan Providers other than          can make an appointment with another Plan
Kaiser Foundation Hospitals and the Medical           Physician. If the Medical Group determines that
Group) are available upon request from our            there isn’t a Plan Physician who is an
Member Service Call Center. Please refer to           appropriately qualified medical professional for
“Post-Stabilization Care” in the “Emergency,          your condition, the Medical Group will authorize
Post-Stabilization, and Urgent Care from Non–         a referral to a Non–Plan Physician for a
Plan Providers” section for authorization             Medically Necessary second opinion.
requirements that apply to Post-Stabilization Care
from Non–Plan Providers.                              Copayments and Coinsurance. The
                                                      Copayments and Coinsurance for these referral
Second Opinions                                       Services are the Copayments and Coinsurance
If you request a second opinion, it will be           required for Services provided by a Plan Provider
provided to you when Medically Necessary by an        as described in the “Benefits, Copayments, and
                                                      Coinsurance” section.
82
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Contracts with Plan Providers                            Physician or other contracting provider as
                                                         determined by the Medical Group
How Plan Providers are paid
                                                       • A high-risk pregnancy or a pregnancy in its
Health Plan and Plan Providers are independent
                                                         second or third trimester. We may cover these
contractors. Plan Providers are paid in a number
                                                         Services through postpartum care related to the
of ways, such as salary, capitation, per diem
                                                         delivery, or longer if Medically Necessary for
rates, case rates, fee for service, and incentive
                                                         a safe transfer of care to a Plan Physician as
payments. To learn more about how Plan
                                                         determined by the Medical Group
Physicians are paid to provide or arrange medical
and hospital care for Members, please ask your
                                                       The Services must be otherwise covered under
Plan Physician or call our Member Service Call
                                                       this DF/EOC. Also, the terminated provider must
Center.
                                                       agree in writing to our contractual terms and
                                                       conditions and comply with them for Services to
Financial liability




                                                                                                              Part Two − Senior Advantage
                                                       be covered by us. The Copayments and
Our contracts with Plan Providers provide that         Coinsurance for the Services of a terminated
you are not liable for any amounts we owe.             provider are the Copayments and Coinsurance
However, you may be liable for the cost of             required for Services provided by a Plan Provider
noncovered Services you obtain from Plan               as described in the “Benefits, Copayments, and
Providers or Non–Plan Providers.                       Coinsurance” section. For more information
                                                       about this provision, or to request the Services,
Termination of a Plan Provider’s contract and          please call our Member Service Call Center.
completion of Services
If our contract with any Plan Provider terminates      Visiting Other Regions
while you are under the care of that provider, we
                                                       If you visit the service area of another Region
will retain financial responsibility for covered
                                                       temporarily (not more than 90 days), you can
care you receive from that provider until we
                                                       receive visiting member care from designated
make arrangements for the Services to be
                                                       providers in that area. Visiting member care is
provided by another Plan Provider and notify you
                                                       described in our visiting member brochure.
of the arrangements.
                                                       Visiting member care and your out-of-pocket
                                                       costs may differ from the covered Services,
Completion of Services. If you are undergoing
                                                       Copayments, and Coinsurance described in this
treatment for specific conditions from a Plan
                                                       DF/EOC.
Physician (or certain other providers) when the
contract with him or her ends (for reasons other
                                                       The 90 day limit on visiting member care does
than medical disciplinary cause, criminal activity,
                                                       not apply to a Dependent child who attends an
or the provider’s voluntary termination), you may
                                                       accredited college or accredited vocational
be eligible to continue receiving covered care
                                                       school. The service areas and facilities where you
from the terminated provider for your condition.
                                                       may obtain visiting member care may change at
                                                       any time without notice.
The conditions that are subject to this
continuation of care provision are:
                                                       Please call our Member Service Call Center for
• Certain conditions that are either acute, or         more information about visiting member care,
  serious and chronic. We may cover these              including facility locations in the service area of
  Services for up to 90 days, or longer                another Region, and to request a copy of the
  if necessary for a safe transfer of care to a Plan   visiting member brochure.


                                                                                                         83
Your Identification Card                              Member Services
Each Member’s Kaiser Permanente identification        Most Plan Facilities have an office staffed with
card has a medical record number on it, which         representatives who can provide assistance if you
you will need when you call for advice, make an       need help obtaining Services. At different
appointment, or go to a provider for covered care.    locations, these offices may be called Member
When you get care, please bring your Kaiser           Services, Patient Assistance, or Customer
Permanente ID card and a photo ID. Your               Service. In addition, our Member Service Call
medical record number is used to identify your        Center representatives are available to assist you
medical records and membership information.           seven days a week from 8 a.m. to 8 p.m. toll free
Your medical record number should never               at 800-443-0815 or 800-777-1370 (TTY for the
change. Please call our Member Service Call           deaf, hard of hearing, or speech impaired). For
Center if we ever inadvertently issue you more        your convenience, you can also contact us
than one medical record number, or if you need        through our Web site at kp.org.
to replace your Kaiser Permanente ID card.
                                                      Member Services representatives at our Plan
Your ID card is for identification only. To receive   Facilities and Member Service Call Center can
covered Services, you must be a current Member.       answer any questions you have about your
Anyone who is not a Member will be billed as a        benefits, available Services, and the facilities
non-Member for any Services he or she receives.       where you can receive care. For example, they
If you let someone else use your ID card, we will     can explain your Health Plan benefits, how to
submit the matter to CalPERS for appropriate          make your first medical appointment, what to do
action as described under “Termination for            if you move, what to do if you need care while
Cause” in the “Termination of Membership”             you are traveling, and how to replace your ID
section.                                              card. These representatives can also help you if
                                                      you need to file a claim as described in the
Your Medicare card                                    “Emergency, Post-Stabilization, and Urgent Care
As a Member, you will not need your red, white,       from Non–Plan Providers” section or with any
and blue Medicare card to get covered Services,       issues as described in the “Grievances” and
but do keep it in a safe place in case you need it    “Requests for Services or Payment, Complaints,
later.                                                and Medicare Appeal Procedures” sections.

Getting Assistance                                    Interpreter services
We want you to be satisfied with the health care      If you need interpreter services when you call us
you receive from Kaiser Permanente. If you have       or when you get covered Services, please let us
any questions or concerns, please discuss them        know. Interpreter services are available 24 hours
with your personal Plan Physician or with other       a day, seven days a week, at no cost to you. For
Plan Providers who are treating you. They are         more information on the interpreter services we
committed to your satisfaction and want to help       offer, please call our Member Service Call
you with your questions.                              Center.




84
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


EMERGENCY, POST-STABILIZATION, AND URGENT CARE
FROM NON–PLAN PROVIDERS

This “Emergency, Post-Stabilization, and Urgent     reasonably expect the absence of immediate
Care from Non–Plan Providers” section explains      medical attention to result in serious jeopardy to
how to obtain covered Emergency Care, Post-         your health or body functions or organs, or (2)
Stabilization Care, and Out-of-Area Urgent Care     active labor when there isn't enough time for safe
from Non–Plan Providers. We do not cover the        transfer to a Plan Hospital (or designated
Non–Plan Provider care discussed in this section    hospital) before delivery or if transfer poses a
unless it meets both of the following               threat to your (or your unborn child's) health and
requirements:                                       safety.
• This “Emergency, Post-Stabilization, and
                                                    For ease and continuity of care, we encourage




                                                                                                          Part Two − Senior Advantage
  Urgent Care from Non–Plan Providers”
  section says that we cover the care               you to go to a Plan Hospital Emergency
                                                    Department listed in Your Guidebook if you are
• The care would be covered under the               inside your Home Region’s Service Area, but
  “Benefits, Copayments, and Coinsurance”           only if it is reasonable to do so, considering your
  section (subject to the “Exclusions,              condition or symptoms.
  Limitations, Coordination of Benefits, and
  Reductions” section) if you received the care
                                                    Post-Stabilization Care
  from a Plan Provider
                                                    Post-Stabilization Care is Medically Necessary
Prior Authorization                                 Services related to your Emergency Medical
                                                    Condition that you receive after your treating
You do not need to get prior authorization from     physician determines that your condition is
us to get Emergency Care or Out-of-Area Urgent      Clinically Stable.
Care from Non–Plan Providers. However, you
must get prior authorization from us for Post-      We cover Post-Stabilization Care if one of the
Stabilization Care from Non–Plan Providers
                                                    following is true:
(prior authorization means that we must approve
the Services in advance for the Services to be      • We provide or authorize the care
covered), except as otherwise described in this     • The care was Medically Necessary to maintain
section.                                              stabilization and it was administered within
                                                      one hour following a request for authorization
Emergency Care                                        and we have not yet responded
If you have an Emergency Medical Condition,         • The Non–Plan Provider and we do not agree
call 911 or go to the nearest hospital (including     about your care and a Plan Physician is not
an emergency room or urgent care center). When        available for consultation
you have an Emergency Medical Condition, we         • In the rare circumstance that we are
cover Emergency Care anywhere in the world.           unavailable or cannot be contacted

An Emergency Medical Condition is: (1) a            Covered Post-Stabilization Care is effective until
medical or psychiatric condition that manifests     one of the following events occurs:
itself by acute symptoms of sufficient severity
                                                    • You are discharged from the Non–Plan
(including severe pain) such that you could
                                                      Hospital

                                                                                                     85
• We assume responsibility for your care              Out-of-Area Urgent Care
• The Non–Plan Provider and we agree to other         If you have an Urgent Care need due to an
  arrangements                                        unforeseen illness or unforeseen injury, we cover
                                                      Medically Necessary Services to prevent serious
To request authorization to receive Post-             deterioration of your health from a Non–Plan
Stabilization Care from a Non–Plan Provider, the      Provider if all of the following are true:
Non–Plan Provider must call us toll free at           • You receive the Services from Non–Plan
800-225-8883 (TTY users call 711) or the                Providers while you are temporarily outside
notification telephone number on your Kaiser            your Home Region’s Service Area
Permanente ID card before you receive the care.
                                                      • You reasonably believed that your health
After we are notified, we will discuss your
                                                        would seriously deteriorate if you delayed
condition with the Non–Plan Provider. If we
                                                        treatment until you returned to your Home
decide that you require Post-Stabilization Care
                                                        Region’s Service Area
and that this care would be covered if you
received it from a Plan Provider, we will
                                                      Follow-up Care
authorize your care from the Non–Plan Provider
or arrange to have a Plan Provider (or other          We do not cover follow-up care provided by
designated provider) provide the care with the        Non–Plan Providers unless it is covered
treating physician’s concurrence. If we decide to     Emergency Care, Post-stabilization Care, or Out-
have a Plan Hospital, Plan Skilled Nursing            of-Area Urgent Care described in this
Facility, or designated Non–Plan Provider             “Emergency, Post-stabilization, and Urgent Care
provide your care, we may authorize special           from Non–Plan Providers” section.
transportation services that are medically required
to get you to the provider. This may include          Payment and Reimbursement
transportation that is otherwise not covered.
                                                      If you receive Emergency Care,
                                                      Post-Stabilization Care, Out-of-Area Urgent
Be sure to ask the Non–Plan Provider to tell you
                                                      Care, or out-of-area dialysis care from a
what care (including any transportation) we have
                                                      Non–Plan Provider ask the Non-Plan Provider to
authorized because we will not cover
                                                      submit a claim to us within 60 days or as soon as
unauthorized Post-Stabilization Care or related
                                                      possible, but no later than 15 months after
transportation provided by Non–Plan Providers,
                                                      receiving the care (or up to 27 months according
except as otherwise described in this section.
                                                      to Medicare rules, in some cases). If the provider
Also, you will only be held financially liable
                                                      refuses to bill us, send us the unpaid bill with a
if you are notified by the Non–Plan Provider or
                                                      claim form. Also, if you receive Services from a
us about your potential liability.
                                                      Plan Provider that are prescribed by a Non–Plan
                                                      Provider in conjunction with covered Emergency
Urgent Care                                           Care, Post-Stabilization Care, and Out-of-Area
Inside the Service Area                               Urgent Care (for example, drugs), you may be
In the event of unusual circumstances that delay      required to pay for the Services and file a claim.
or render impractical the provision of Services
under this DF/EOC (such as major disaster,            How to file a claim
epidemic, war, riot, and civil insurrection), we      To file a claim, this is what you need to do:
cover Urgent Care inside your Home Region’s
                                                      • As soon as possible, request our claim form by
Service Area from a Non–Plan Provider.
                                                        calling our Member Service Call Center toll

86
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  free at 800-443-0815 or 800-390-3510 (TTY          any insurance policy, or any other contract or
  users call 800-777-1370). One of our               coverage, or any government program except
  representatives will be happy to assist you        Medicaid.
  if you need help completing our claim form
• If you have paid for Services, you must send
  us our completed claim form for
  reimbursement. Please attach any bills and
  receipts from the Non–Plan Provider
• You must complete and return to us any
  information that we request to process your
  claim, such as claim forms, consents for the
  release of medical records, assignments, and
  claims for any other benefits to which you may




                                                                                                           Part Two − Senior Advantage
  be entitled. For example, we may require
  documents such as travel documents or
  original travel tickets to validate your claim
• The completed claim form must be mailed to
  the following address as soon as possible, but
  no later than 15 months after receiving the care
  (or up to 27 months according to Medicare
  rules, in some cases). Please do not send any
  bills or claims to Medicare. Any additional
  information we request should also be mailed
  to this address:

   For Northern California Members
   Kaiser Foundation Health Plan, Inc.
   Claims Department
   P.O. Box 24010
   Oakland, CA 94623-1010

   For Southern California Members
   Kaiser Foundation Health Plan, Inc.
   Claims Department
   P.O. Box 7004
   Downey, CA 90242-7004

We will reduce any payment we make to you or
the Non–Plan Provider by applicable Copayments
and Coinsurance.

Also, if Medicare is the secondary payer by law,
we will reduce our payment by any amounts paid
or payable (or that in the absence of this plan
would have been payable) for the Services under


                                                                                                      87
BENEFITS, COPAYMENTS, AND COINSURANCE

We cover the Services described in this             ♦   authorized referrals as described under
“Benefits, Copayments, and Coinsurance”                 “Getting a Referral” in the “How to Obtain
section, subject to all provisions in the               Services” section
“Exclusions, Limitations, Coordination of           ♦   chiropractic services as described in the
Benefits, and Reductions” section, only if all of       “ASH Plans Chiropractic Services” section
the following conditions are satisfied:                 in Part Two of this DF/EOC, and for
• You are a Member on the date that you receive         Southern California Region Members,
  the Services                                          chiropractic services as described under
• The Services are Medically Necessary                  “Chiropractic Services” in this “Benefits,
                                                        Copayments, and Coinsurance” section
• The Services are provided, prescribed,
                                                    ♦   durable medical equipment as described
  authorized, or directed by a Plan Physician
                                                        under “Durable Medical Equipment for
  except where specifically noted to the contrary
                                                        Home Use” in the “Benefits, Copayments,
  in the sections listed below for the following
                                                        and Coinsurance” section
  Services:
                                                    ♦   emergency ambulance Services as described
  ♦ chiropractic services as described in the
                                                        under “Ambulance Services” in the
     “ASH Plans Chiropractic Services” section
                                                        “Benefits, Copayments, and Coinsurance”
     in Part Two of this DF/EOC, and for
                                                        section
     Southern California Region Members,
     chiropractic services as described under       ♦   Emergency Care, Post-Stabilization Care,
     “Chiropractic Services” in this “Benefits,         and Urgent Care as described in the
     Copayments, and Coinsurance” section               “Emergency, Post-Stabilization, and Urgent
                                                        Care from Non–Plan Providers” section
  ♦ emergency ambulance Services as described
     under “Ambulance Services” in this             ♦   home health care as described under “Home
     “Benefits, Copayments, and Coinsurance”            Health Care” in the “Benefits, Copayments,
     section                                            and Coinsurance” section
  ♦ Emergency Care, Post-Stabilization Care,        ♦   ostomy and urological supplies as described
     and Out-of-Area Urgent Care as described           under “Ostomy and Urological Supplies” in
     in the “Emergency, Post-Stabilization, and         the “Benefits, Copayments, and
     Urgent Care from Non–Plan Providers”               Coinsurance” section
     section                                        ♦   out-of-area dialysis care as described under
  ♦ out-of-area dialysis care as described under        “Dialysis Care” in the “Benefits,
     “Dialysis Care” in this “Benefits,                 Copayments, and Coinsurance” section
     Copayments, and Coinsurance” section           ♦   prescription drugs from Non–Plan
  ♦ visiting member care as described under             Pharmacies as described under “Outpatient
     “Visiting Other Regions” in the “How to            Prescription Drugs, Supplies, and
     Obtain Services” section                           Supplements” in the “Benefits,
                                                        Copayments, and Coinsurance” section
• You receive the Services from Plan Providers
  inside your Home Region’s Service Area,           ♦   prosthetic and orthotic devices as described
  except where specifically noted to the contrary       under “Prosthetic and Orthotic Devices” in
  in the sections listed below for the following        the “Benefits, Copayments, and
  Services:                                             Coinsurance” section

88
        Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


   ♦   visiting member care as described under           specialist visits. Similarly, if your physician
       “Visiting Other Regions” in the “How to           performs a procedure immediately after a
       Obtain Services” section                          consultation, you may have to pay separate
                                                         Copayments or Coinsurance amounts for the
The only Services we cover under this DF/EOC             consultation visit and for the procedure. If you
are those that this “Benefits, Copayments, and           have questions about Copayments and
Coinsurance” section says that we cover, subject         Coinsurance, please contact our Member Service
to exclusions and limitations described in this          Call Center.
“Benefits, Copayments, and Coinsurance” section
and to all provisions in the “Exclusions,                In some cases, we may agree to bill you for your
Limitations, Coordination of Benefits, and               Copayments and Coinsurance amount.
Reductions” section. The “Exclusions,
Limitations, Coordination of Benefits, and               Copayment and Coinsurance
Reductions” section describes exclusions,




                                                                                                               Part Two − Senior Advantage
                                                         The Copayment or Coinsurance you must pay for
limitations, reductions, and coordination of
                                                         each covered Service is described in this
benefits provisions that apply to all Services that
                                                         “Benefits, Copayments, and Coinsurance”
would otherwise be covered. When an exclusion
                                                         section. Copayments and Coinsurance are due at
or limitation applies only to a particular benefit, it
                                                         the time you receive the Services, except for the
is listed in the description of that benefit in this
                                                         following:
“Benefits, Copayments, and Coinsurance”
section. Also, please refer to:                          • For items ordered in advance, you pay the
                                                           Copayment or Coinsurance in effect on the
• The “Emergency, Post-Stabilization, and
                                                           order date (although we will not cover the item
  Urgent Care from Non–Plan Providers”
                                                           unless you still have coverage for it on the date
  section for information about how to obtain
                                                           you receive it) and you may be required to pay
  covered Emergency Care, Post-Stabilization
                                                           the Copayment or Coinsurance before the item
  Care, and Out-of-Area Urgent Care from
                                                           is ordered. For outpatient prescription drugs,
  Non–Plan Providers
                                                           the order date is the date that the pharmacy
• Your Guidebook for the types of covered                  processes the order after receiving all the
  Services that are available from each Plan               information they need to fill the prescription.
  Facility in your area, because some facilities
                                                         • Before starting or continuing a course of
  provide only specific types of covered
                                                           infertility Services, you may be required to pay
  Services
                                                           initial and subsequent deposits toward your
                                                           Copayment or Coinsurance for some or all of
Copayments and Coinsurance                                 the entire course of Services, along with any
At the time you receive covered Services, you              past-due infertility-related Copayment or
must pay your Copayments and Coinsurance                   Coinsurance. Any unused portion of your
amounts as described in this “Benefits,                    deposit will be returned to you. When a
Copayments, and Coinsurance” section. If you               deposit is not required, you must pay your
receive more than one Service from a provider, or          Copayment or Coinsurance for the procedure,
Services from more than one provider, you may              along with any past-due infertility-related
be required to pay separate Copayments or                  Copayment or Coinsurance before you can
Coinsurance amounts for each Service and each              schedule an infertility procedure
provider. For example, if you receive Services
from two specialists in one visit, you may have to
pay the Copayments or Coinsurance for two

                                                                                                         89
Annual out-of-pocket maximum                         • Office visits (including professional Services
There is a limit to the total amount of                such as dialysis treatment, diabetes
Copayments and Coinsurance you must pay                monitoring, health education, and manual
under this DF/EOC in a calendar year for all of        manipulation of the spine to correct
the covered Services listed below that you receive     subluxation covered by Medicare)
in the same calendar year.                           • Outpatient surgery
                                                     • Rehabilitation Services, including care in a
The limit is one of the following amounts:
                                                       Comprehensive Outpatient Rehabilitation
• $1,500 per calendar year for self-only               Facility
  enrollment (a Family of one Member)
• $1,500 per calendar year for any one Member        Special Note about Clinical Trials
  in a Family of two or more Members                 We do not cover clinical trials because they are
• $3,000 per calendar year for an entire Family      experimental or investigational, but you do have
  of two or more Members                             coverage through Original Medicare for certain
                                                     clinical trials. Original Medicare covers routine
If you are a Member in a Family of two or more       costs if you take part in a clinical trial that meets
Members, you reach the annual out-of-pocket          Medicare requirements. Routine costs include
maximum either when you meet the maximum             costs like room and board for a hospital stay that
for any one Member, or when your Family              Medicare would pay for even if you weren't in a
reaches the Family maximum. For example,             trial, an operation to implant an item that is being
suppose you have reached the $1,500 maximum.         tested, and items and services to treat side effects
For Services subject to the maximum, you will        and complications arising from the new care.
not pay any more Copayments or Coinsurance           Generally, Medicare will not cover the costs of
during the rest of the calendar year, but each       experimental care, such as the drugs or devices
other Member in your Family must continue to         being tested in a clinical trial.
pay Copayments or Coinsurance during the             There are certain requirements for Medicare
calendar year until your Family reaches the          coverage of clinical trials. If you participate as a
$3,000 maximum.                                      patient in a clinical trial that meets Medicare
                                                     requirements, the Original Medicare Plan (and
Payments that count toward the maximum.              not Senior Advantage) pays the clinical trial
The Copayments and Coinsurance you pay for           doctors and other providers for the covered
the following Services apply toward the annual       services you get that are related to the clinical
out-of-pocket maximum:                               trial. When you are in a clinical trial, you may
• Dental Services covered by Medicare                stay enrolled in Senior Advantage. You should
                                                     continue to come to Plan Providers for all
• Diabetic monitoring devices                        covered Services that are not part of the clinical
• Durable medical equipment                          trial.
• Emergency Department and Out-of-Area
  Urgent Care visits                                 You will have to pay the same coinsurance
                                                     amounts charged under Original Medicare for the
• Imaging, laboratory, and special procedures        services you receive when participating in a
• Medicare Part B drugs                              qualifying clinical trial. To find out how much
• Mental health care, intensive psychiatric          you will have to pay for Medicare covered
  treatment programs                                 clinical trials, please refer to the “Medicare &
                                                     You” handbook. Also, to learn more about what

90
       Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Medicare covers, please refer to the “Medicare        • Outpatient surgery and other outpatient
and Clinical Trials” brochure. To get a free copy,      procedures: a $10 Copayment
call Medicare directly toll free at                     per procedure
800-MEDICARE (800-633-4227) (TTY users                • Voluntary termination of pregnancy:
call 877-486-2048) 24 hours a day, seven days a         a $10 Copayment per procedure
week, or visit www.medicare.gov on the Web.
                                                      • Physical, occupational, and speech therapy in
You don't need to get a referral from a Plan            accord with Medicare guidelines:
Provider to join a clinical trial covered by            a $10 Copayment per visit
Medicare, and the clinical trial providers don't      • Physical, occupational, and speech therapy
need to be Plan Providers. However, you should          provided in our organized, multidisciplinary
tell us before you join a clinical trial outside of     rehabilitation day-treatment program in accord
Kaiser Permanente so we can keep track of your          with Medicare guidelines: a $10 Copayment
Services.                                               per day




                                                                                                            Part Two − Senior Advantage
                                                      • Urgent Care visits: a $10 Copayment
Outpatient Care                                         per visit
We cover the following outpatient care for            • Emergency Department visits:
preventive medicine, diagnosis, and treatment           a $50 Copayment per visit. This Copayment
subject to the Copayment or Coinsurance                 does not apply if you are admitted directly to
indicated:                                              the hospital as an inpatient within 24 hours for
• Routine preventive care:                              the same condition or if you are held for
                                                        observation in a hospital unit outside the
  ♦ physical exams, including well-woman
                                                        Emergency Department
    visits and the Welcome to Medicare Exam
    during the first year after Part B enrollment     • House calls by a Plan Physician (or a Plan
    in accord with Medicare guidelines:                 Provider who is a registered nurse) inside your
    a $10 Copayment per visit                           Home Region’s Service Area when care can
  ♦ family planning visits for counseling, or to
                                                        best be provided in your home as determined
    obtain emergency contraceptive pills,               by a Plan Physician: no charge
    injectable contraceptives, internally             • Blood, blood products, and their
    implanted time-release contraceptives, or           administration: no charge
    intrauterine devices (IUDs):                      • Administered drugs (drugs, injectables,
    a $10 Copayment per visit                           radioactive materials used for therapeutic
  ♦ after confirmation of pregnancy, the normal         purposes, and allergy test and treatment
    series of regularly scheduled preventive            materials) prescribed in accord with our drug
    care prenatal visits and the first postpartum       formulary guidelines, if administration or
    visit: a $10 Copayment per visit                    observation by medical personnel is required
  ♦ vaccines (immunizations) covered by                 and they are administered to you in a Plan
    Medicare Part B and administered to you in          Medical Office or during home visits:
    a Plan Medical Office: no charge                    no charge
• Primary and specialty care visits:                  • Preventive health screenings, such as
  a $10 Copayment per visit                             screening and tests for colorectal cancer in
                                                        accord with Medicare guidelines:
• Allergy injection visits: a $3 Copayment
                                                        a $10 Copayment per procedure
  per visit



                                                                                                       91
• Some types of outpatient visits may be            Hospital Inpatient Care
  available as group appointments, which are
                                                    We cover the following inpatient Services at
  covered at a $5 Copayment per visit
                                                    no charge in a Plan Hospital, when the Services
                                                    are generally and customarily provided by acute
Note: Vaccines covered by Medicare Part D are
                                                    care general hospitals inside your Home Region’s
not covered under this “Outpatient Care” section
                                                    Service Area:
(instead, refer to the “Outpatient Prescription
Drugs, Supplies, and Supplements” section in this   • Room and board, including a private room
“Benefits, Copayments, and Coinsurance”               if Medically Necessary
section).                                           • Specialized care and critical care units
                                                    • General and special nursing care
The following types of outpatient Services are
covered only as described under these headings in   • Operating and recovery rooms
this “Benefits, Copayments, and Coinsurance”        • Services of Plan Physicians, including
section:                                              consultation and treatment by specialists
• Chemical Dependency Services                      • Anesthesia
• Chiropractic Services                             • Drugs prescribed in accord with our drug
• Dental Services for Radiation Treatment and         formulary guidelines (for discharge drugs
  Dental Anesthesia                                   prescribed when you are released from the
                                                      hospital, please refer to “Outpatient
• Dialysis Care                                       Prescription Drugs, Supplies, and
• Durable Medical Equipment for Home Use              Supplements” in this “Benefits, Copayments,
• Health Education                                    and Coinsurance” section)
• Hearing Services                                  • Radioactive materials used for therapeutic
                                                      purposes
• Home Health Care
                                                    • Durable medical equipment and medical
• Hospice Care                                        supplies
• Infertility Services                              • Imaging, laboratory, and special procedures
• Mental Health Services                            • Blood, blood products, and their
• Ostomy and Urological Supplies                      administration
• Outpatient Imaging, Laboratory, and Special       • Obstetrical care and delivery (including
  Procedures                                          cesarean section). Note: If you are discharged
• Outpatient Prescription Drugs, Supplies, and        within 48 hours after delivery (or within 96
  Supplements                                         hours if delivery is by cesarean section), your
                                                      Plan Physician may order a follow-up visit for
• Prosthetic and Orthotic Devices                     you and your newborn to take place within 48
• Reconstructive Surgery                              hours after discharge
• Transplant Services                               • Physical, occupational, and speech therapy
• Vision Services                                     (including treatment in our organized,
                                                      multidisciplinary rehabilitation program) in
                                                      accord with Medicare guidelines
                                                    • Respiratory therapy
                                                    • Medical social services and discharge planning
92
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


The following types of inpatient Services are          requires the use of Services that only a licensed
covered only as described under the following          ambulance can provide and that the use of other
headings in this “Benefits, Copayments, and            means of transportation would endanger your
Coinsurance” section:                                  health. These Services are covered only when the
• Chemical Dependency Services                         vehicle transports you to or from covered
                                                       Services in accord with Medicare guidelines.
• Dental Services for Radiation Treatment and
  Dental Anesthesia
                                                       Ambulance Services exclusion
• Dialysis Care
                                                       • Transportation by car, taxi, bus, gurney van,
• Hospice Care                                           wheelchair van, and any other type of
• Infertility Services                                   transportation (other than a licensed
                                                         ambulance), even if it is the only way to travel
• Mental Health Services
                                                         to a Plan Provider
• Prosthetic and Orthotic Devices




                                                                                                            Part Two − Senior Advantage
• Reconstructive Surgery                               Chemical Dependency Services
• Religious Nonmedical Health Care Institution         Inpatient detoxification
  Services                                             We cover hospitalization at no charge in a Plan
• Skilled Nursing Facility Care                        Hospital only for medical management of
• Transplant Services                                  withdrawal symptoms, including room and board,
                                                       Plan Physician Services, drugs, dependency
                                                       recovery Services, education, and counseling.
Ambulance Services
Emergency                                              Outpatient chemical dependency care
When you have an Emergency Medical                     We cover the following Services for treatment of
Condition, we cover emergency Services of a            chemical dependency:
licensed ambulance anywhere in the world at            • Day-treatment programs
no charge. In accord with the “Emergency,
Post-Stabilization, and Urgent Care from               • Intensive outpatient programs
Non–Plan Providers” section, we cover                  • Individual and group chemical dependency
emergency ambulance Services that are not                counseling visits
ordered by us only if one of the following is true:    • Visits for the purpose of medical treatment for
• Your treating physician determines that you            withdrawal symptoms
  must be transported to another facility when
  you are not Clinically Stable because the care       You pay the following for these covered
  you need is not available at the treating facility   Services:
• You are not already being treated, and you           • Individual visits: a $10 Copayment per visit
  reasonably believe that your condition requires
                                                       • Group visits: a $5 Copayment per visit
  ambulance transportation
                                                       We cover methadone maintenance treatment at
Nonemergency
                                                       no charge for pregnant Members during
Inside your Home Region’s Service Area, we             pregnancy and for two months after delivery at a
cover nonemergency ambulance Services in               licensed treatment center approved by the
accord with Medicare guidelines at no charge           Medical Group. We do not cover methadone
if a Plan Physician determines that your condition

                                                                                                       93
maintenance treatment in any other                   Additional chiropractic coverage
circumstances.                                       Please see the “ASH Plans Chiropractic Services”
                                                     section in Part Two of this DF/EOC for
Transitional residential recovery Services           information about chiropractic services we cover
We cover chemical dependency treatment in a          through American Specialty Health Plans (ASH
nonmedical transitional residential recovery         Plans).
setting approved in writing by the Medical
Group. We cover these Services at no charge.         Dental Services for Radiation Treatment
These settings provide counseling and support        and Dental Anesthesia
services in a structured environment.
                                                     Dental Services for radiation treatment
Note: The following Services are not covered         We cover services covered by Medicare,
under this “Chemical Dependency Services”            including dental evaluation, X-rays, fluoride
section:                                             treatment, and extractions necessary to prepare
                                                     your jaw for radiation therapy of cancer in your
• Outpatient laboratory Services (instead, refer
                                                     head or neck at a $10 Copayment per visit if a
  to the “Outpatient Imaging, Laboratory, and
                                                     Plan Physician provides the Services or if the
  Special Procedures” section in this “Benefits,
                                                     Medical Group authorizes a referral to a dentist
  Copayments, and Coinsurance” section)
                                                     (as described in “Medical Group authorization
• Outpatient prescription drugs (instead, refer to   procedure for certain referrals” under “Getting a
  the “Outpatient Prescription Drugs, Supplies,      Referral” in the “How to Obtain Services”
  and Supplements” section in this “Benefits,        section).
  Copayments, and Coinsurance” section)
                                                     Dental anesthesia
Chemical dependency Services exclusion               For dental procedures at a Plan Facility, we
• Services in a specialized facility for             provide general anesthesia and the facility’s
  alcoholism, drug abuse, or drug addiction          Services associated with the anesthesia if all of
  except as otherwise described in this              the following are true:
  “Chemical Dependency Services” section             • You are developmentally disabled, or your
                                                       health is compromised
Chiropractic Services                                • Your clinical status or underlying medical
Manual manipulation covered by Medicare                condition requires that the dental procedure be
Manual manipulation of the spine is provided at        provided in a hospital or outpatient surgery
a $10 Copayment per visit to correct                   center
subluxation, as covered by Medicare, but only if     • The dental procedure would not ordinarily
the manipulation is performed for Southern             require general anesthesia
California Region Members by an American
Specialty Health Plans (ASH Plans) Participating     We do not cover any other Services related to the
Chiropractor (no referral required), or when         dental procedure, such as the dentist’s Services,
prescribed by a Plan Physician and performed by      unless the Service is covered by Medicare.
a Plan osteopath or chiropractor for Northern
California Region Members.                           For covered dental anesthesia Services, you will
                                                     pay the Copayments and Coinsurance that you
                                                     would pay for hospital inpatient care or
                                                     outpatient surgery, depending on the setting.

94
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Note: Outpatient prescription drugs are not         Note: The following Services are not covered
covered under this “Dental Services for Radiation   under this “Dialysis Care” section:
Treatment and Dental Anesthesia” section            • Laboratory Services (instead, refer to the
(instead, refer to the “Outpatient Prescription       “Outpatient Imaging, Laboratory, and Special
Drugs, Supplies, and Supplements” section in this     Procedures” section in this “Benefits,
“Benefits, Copayments, and Coinsurance”               Copayments, and Coinsurance” section)
section).
                                                    • Outpatient prescription drugs (instead, refer to
                                                      the “Outpatient Prescription Drugs, Supplies,
Dialysis Care
                                                      and Supplements” section in this “Benefits,
We cover acute and chronic dialysis Services if       Copayments, and Coinsurance” section)
all of the following requirements are met:
                                                    • Outpatient administered drugs (instead, refer
• You satisfy all medical criteria developed by       to the “Outpatient Care” section in this
  the Medical Group                                   “Benefits, Copayments, and Coinsurance”




                                                                                                         Part Two − Senior Advantage
• The facility is certified by Medicare               section)
• A Plan Physician provides a written referral
                                                    Durable Medical Equipment for Home
  for your dialysis treatment except for out-of-
  area dialysis care                                Use
                                                    Inside your Home Region’s Service Area, we
We also cover peritoneal home dialysis              cover durable medical equipment (DME) for use
(including equipment, training, and medical         in your home (or another location used as your
supplies).                                          home as defined by Medicare) in accord with our
                                                    DME formulary and Medicare guidelines.
Out-of-area dialysis care                           However, we will cover DME described in this
We cover dialysis (kidney) Services at a            section if you were enrolled in Senior Advantage
Medicare-certified dialysis facility that you get   on December 31, 1998, and you lived inside
when you are temporarily outside our Service        California, but outside your Home Region’s
Area. If possible, before you leave the Service     Service Area, and you continue to live at the
Area, please let us know where you are going so     same address. DME for home use is an item that
we can help arrange for you to have maintenance     is intended for repeated use, primarily and
dialysis while outside our Service Area.            customarily used to serve a medical purpose,
Note: The procedure for obtaining reimbursement     generally not useful to a person who is not ill or
for out-of-area dialysis care is described in the   injured, and appropriate for use in the home.
“Emergency, Post-Stabilization, and Urgent Care
from Non–Plan Providers” section.                   Coverage is limited to the standard item of
                                                    equipment that adequately meets your medical
You pay the following for these covered Services    needs. Covered DME, including repair and
related to dialysis:                                replacement of covered DME, is covered at
                                                    no charge.
• Inpatient dialysis care: no charge
• One routine office visit per month with the       We decide whether to rent or purchase the
  multidisciplinary nephrology team: no charge      equipment, and we select the vendor. We will
• All other office visits: a $10 Copayment          repair or replace the equipment, unless the repair
  per visit                                         or replacement is due to misuse.
• Hemodialysis treatment: no charge


                                                                                                    95
Durable medical equipment items for diabetes        “Outpatient Prescription Drugs, Supplies, and
The following diabetes blood-testing supplies and   Supplements” section in this “Benefits,
equipment and insulin-administration devices are    Copayments, and Coinsurance” section).
covered under this “Durable Medical Equipment
for Home Use” section:                              Durable medical equipment for home use
• Blood glucose monitors and their supplies         exclusions
  (such as blood glucose monitor test strips,       • Comfort, convenience, or luxury equipment or
  lancets, and lancet devices)                        features
• Insulin pumps and supplies to operate the         • Exercise or hygiene equipment
  pump
                                                    • Dental appliances

About our DME formulary                             • Nonmedical items, such as sauna baths or
                                                      elevators
Our DME formulary includes the list of DME
that is covered by Medicare or has been approved    • Modifications to your home or car
by our DME Formulary Executive Committee for        • Devices for testing blood or other body
our Members. Our DME formulary was                    substances (except diabetes blood glucose
developed by a multidisciplinary clinical and         monitors and their supplies)
operational work group with review and input
                                                    • Electronic monitors of the heart or lungs
from Plan Physicians and medical professionals
                                                      except infant apnea monitors
with DME expertise (for example, physical,
respiratory, and enterostomal therapists and home
health). A multidisciplinary DME Formulary
                                                    Health Education
Executive Committee is responsible for              We cover a variety of healthy living (health
reviewing and revising the DME formulary. Our       education) programs to help you take an active
DME formulary is periodically updated to keep       role in protecting and improving your health,
pace with changes in medical technology,            including programs for tobacco cessation, stress
Medicare guidelines, and clinical practice. To      management, and chronic conditions (such as
find out whether a particular DME item is           diabetes and asthma). We cover individual office
included in our DME formulary, please call our      visits at a $10 Copayment per visit. We provide
Member Service Call Center.                         all other covered Services at no charge. You can
                                                    also participate in programs that we don’t cover,
Our formulary guidelines allow you to obtain        which may require that you pay a fee.
nonformulary DME items (those not listed on our
DME formulary for your condition) if they would     For more information about our healthy living
otherwise be covered and the Medical Group          programs, please contact your local Health
determines that they are Medically Necessary as     Education Department or call our Member
described in “Medical Group authorization           Service Call Center, or go to our Web site at
procedure for certain referrals” under “Getting a   kp.org. Your Guidebook also includes
Referral” in the “How to Obtain Services”           information about our healthy living programs.
section.
                                                    Note: In accord with Medicare guidelines, any
Note: Diabetes urine-testing supplies and other     diabetes self-management training courses
insulin-administration devices are not covered      accredited by the American Diabetes Association
under this “Durable Medical Equipment for           may be available to you if you receive a referral
Home Use” section (instead, refer to the            from a Plan Physician.

96
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Hearing Services                                       “Benefits, Copayments, and Coinsurance”
                                                       section)
We cover the following:
• Hearing tests to determine the need for hearing    Hearing Services exclusions
  correction: a $10 Copayment per visit
                                                     • Internally implanted hearing aids
• Hearing tests to determine the appropriate
  hearing aid: no charge                             • Replacement parts and batteries, repair of
                                                       hearing aids, and replacement of lost or broken
• A $1,000 Allowance toward the purchase               hearing aids (the manufacturer warranty may
  price of hearing aid(s) every 36 months when         cover some of these)
  prescribed by a Plan Physician or by a Plan
  Provider who is an audiologist. We will cover
                                                     Home Health Care
  hearing aids for both ears only if both aids are
  required to provide significant improvement        Home health care means Services provided in the




                                                                                                             Part Two − Senior Advantage
  that is not obtainable with only one hearing       home by nurses, medical social workers, home
  aid. We will not provide the Allowance if we       health aides, and physical, occupational, and
  have provided an Allowance toward (or              speech therapists.
  otherwise covered) a hearing aid for that ear
  within the previous 36 months. Also, the           We cover part-time or intermittent home health
  Allowance can only be used at the initial point    care in accord with Medicare guidelines at
  of sale. If you do not use all of your             no charge only if all of the following are true:
  Allowance at the initial point of sale, you        • You are substantially confined to your home
  cannot use it later
                                                     • Your condition requires the Services of a
• Visits to verify that the hearing aid conforms       nurse, physical therapist, or speech therapist
  to the prescription: no charge                       (home health aide Services are not covered
• Visits for fitting, counseling, adjustment,          unless you are also getting covered home
  cleaning, and inspection after the warranty is       health care from a nurse, physical therapist, or
  exhausted: no charge                                 speech therapist that only a licensed provider
                                                       can provide)
We select the provider or vendor that will furnish   • A Plan Physician determines that it is feasible
the covered hearing aid. Coverage is limited to        to maintain effective supervision and control
the types and models of hearing aids furnished by      of your care in your home and that the
the provider or vendor.                                Services can be safely and effectively provided
                                                       in your home
Note: The following Services are not covered
                                                     • The Services are provided inside your Home
under this “Hearing Services” section:
                                                       Region’s Service Area. However, we will
• Services related to the ear or hearing other         cover home health care if you were enrolled in
  than those related to hearing aids described in      Senior Advantage on December 31, 1998 and
  this section (instead, refer to the applicable       lived inside California, but outside your Home
  heading in this “Benefits, Copayments, and           Region’s Service Area, and you continue to
  Coinsurance” section)                                live at the same address
• Cochlear implants and osseointegrated              • The Services are covered by Medicare, such as
  external hearing devices (instead, refer to          part-time or intermittent skilled nursing care
  “Prosthetic and Orthotic Devices” in this            and part-time or intermittent Services of a
                                                       home health aide


                                                                                                        97
The following types of Services are covered in          or 30 minutes from our Service Area if you
the home only as described under these headings         live outside our Service Area, and you have
in this “Benefits, Copayments, and Coinsurance”         been a Senior Advantage Member
section:                                                continuously since before January 1, 1999, at
• Dialysis Care                                         the same home address)

• Durable Medical Equipment for Home Use              • The Services are provided by a licensed
                                                        hospice agency that is a Plan Provider
• Ostomy and Urological Supplies
                                                      • The Services are necessary for the palliation
• Outpatient Prescription Drugs, Supplies, and          and management of your terminal illness and
  Supplements                                           related conditions
• Prosthetic and Orthotic Devices
                                                      If all of the above requirements are met, we cover
Home health care exclusion                            the following hospice Services, which are
                                                      available on a 24-hour basis if necessary for your
• Care in the home if the home is not a safe and      hospice care:
  effective treatment setting
                                                      • Plan Physician Services
Hospice Care                                          • Skilled nursing care, including assessment,
                                                        evaluation, and case management of nursing
Hospice care is a specialized form of
                                                        needs, treatment for pain and symptom
interdisciplinary health care designed to provide
                                                        control, provision of emotional support to you
palliative care and to alleviate the physical,
                                                        and your family, and instruction to caregivers
emotional, and spiritual discomforts of a Member
experiencing the last phases of life due to a         • Physical, occupational, or speech therapy for
terminal illness. It also provides support to the       purposes of symptom control or to enable you
primary caregiver and the Member's family. A            to maintain activities of daily living
Member who chooses hospice care is choosing to        • Respiratory therapy
receive palliative care for pain and other
                                                      • Medical social services
symptoms associated with the terminal illness,
but not to receive care to try to cure the terminal   • Home health aide and homemaker services
illness. You may change your decision to receive      • Palliative drugs prescribed for pain control and
hospice care benefits at any time.                      symptom management of the terminal illness
                                                        for up to a 100-day supply in accord with our
We cover the hospice Services listed below at           drug formulary guidelines. You must obtain
no charge only if all of the following                  these drugs from Plan Pharmacies. Certain
requirements are met:                                   drugs are limited to a maximum 30-day supply
• You are not entitled to Medicare Part A (if you       in any 30-day period (please call our Member
  are entitled to Medicare Part A, see the              Service Call Center for the current list of these
  “Special note if you have Medicare Part A” for        drugs)
  more information)                                   • Durable medical equipment
• A Plan Physician has diagnosed you with a           • Respite care when necessary to relieve your
  terminal illness and determines that your life        caregivers. Respite care is occasional short-
  expectancy is 12 months or less                       term inpatient care limited to no more than
• The Services are provided inside our Service          five consecutive days at a time
  Area (or inside California but within 15 miles      • Counseling and bereavement services

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      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


• Dietary counseling                                You pay the following for these Services related
• The following care during periods of crisis       to involuntary infertility:
  when you need continuous care to achieve          • Office visits: a $10 Copayment per visit
  palliation or management of acute medical         • Outpatient surgery and other outpatient
  symptoms:                                           procedures: a $10 Copayment per procedure
  ♦ nursing care on a continuous basis for as
                                                    • Outpatient laboratory, imaging, and special
    much as 24 hours a day as necessary to
                                                      procedures: no charge
    maintain you at home
                                                    • Hospital inpatient care (including room and
  ♦ short-term inpatient care required at a level
                                                      board, imaging, laboratory, and special
    that cannot be provided at home
                                                      procedures, and Plan Physician Services):
                                                      no charge
Special note if you have Medicare Part A
You may receive care from any Medicare-




                                                                                                            Part Two − Senior Advantage
                                                    Note: Outpatient drugs, supplies, and
certified hospice program. The Original Medicare    supplements are not covered under this
plan (rather than our Plan) will pay the hospice    “Infertility Services” section (instead, refer to the
provider for the services you receive. Your         “Outpatient Prescription Drugs, Supplies, and
hospice provider can be a Plan Provider or a        Supplements” section in this “Benefits,
Non–Plan Provider. If you elect hospice care, you   Copayments, and Coinsurance” section for drug
are not entitled to any other benefits for the      coverage, including the Coinsurance that applies
terminal illness under this DF/EOC or Medicare.     for infertility drugs, which is listed under
However, we will continue to cover the Services     “Copayments and Coinsurance for outpatient
described in this DF/EOC that are not related to    drugs, supplies, and supplements” section).
the terminal illness. Also, we do cover hospice
consultation services for terminally ill Members    Infertility Services exclusions
who have not yet elected the hospice benefit. You
may change your decision to receive hospice care    • Services to reverse voluntary, surgically
at any time.                                          induced infertility
                                                    • Semen and eggs (and Services related to their
For more information on hospice care, visit           procurement and storage)
www.medicare.gov, and under “Search Tools,”
choose “Find a Medicare Publication” to view or     Mental Health Services
download the publication “Medicare Hospice
Benefits.” Or call 800-MEDICARE                     We cover mental health Services as specified in
(800-633-4227). TTY users should call               this “Mental Health Services” section
877-486-2048.
                                                    Outpatient mental health Services
                                                    We cover:
Infertility Services
                                                    • Individual and group visits for diagnostic
We cover the following Services related to            evaluation and psychiatric treatment
involuntary infertility:
                                                    • Psychological testing
• Services for diagnosis and treatment of
                                                    • Visits for the purpose of monitoring drug
  involuntary infertility
                                                      therapy
• Artificial insemination



                                                                                                      99
You pay the following for these covered              Ostomy and Urological Supplies
Services:
                                                     Inside your Home Region’s Service Area, we
• Individual visits: a $10 Copayment                 cover ostomy and urological supplies prescribed
  per visit                                          in accord with our soft goods formulary and
• Group visits: a $5 Copayment per visit             Medicare guidelines at no charge. We select the
                                                     vendor, and coverage is limited to the standard
Note: Outpatient intensive psychiatric treatment     supply that adequately meets your medical needs.
programs are not covered under this “Outpatient
mental health Services” section (refer to            Note: We will cover ostomy and urological
“Intensive psychiatric treatment programs” in this   supplies described in this section if you were
“Mental Health Services” section).                   enrolled in Senior Advantage on December 31,
                                                     1998 and lived inside California, but outside your
Inpatient psychiatric hospitalization and            Home Region’s Service Area, and you continue
intensive psychiatric treatment programs             to live at the same address.

                                                     About our soft goods formulary
Inpatient psychiatric hospitalization. We cover
acute psychiatric conditions in a Medicare-          Our soft goods formulary includes the list of
certified psychiatric hospital at no charge.         ostomy and urological supplies that are covered
                                                     by Medicare or have been approved by our Soft
Intensive psychiatric treatment programs. We         Goods Formulary Executive Committee for our
cover at no charge the following intensive           Members. Our Soft Goods Formulary Executive
psychiatric treatment programs in a Plan Facility:   Committee is responsible for reviewing and
                                                     revising the soft goods formulary. Our soft goods
• Short-term hospital-based intensive outpatient
                                                     formulary is periodically updated to keep pace
  care (partial hospitalization)
                                                     with changes in medical technology, Medicare
• Short-term multidisciplinary treatment in an       guidelines, and clinical practice. To find out
  intensive outpatient psychiatric treatment         whether a particular ostomy or urological supply
  program                                            is included in our soft goods formulary, please
• Short-term treatment in a crisis residential       call our Member Service Call Center.
  program in licensed psychiatric treatment
  facility with 24-hour a day monitoring by          Our formulary guidelines allow you to obtain
  clinical staff for stabilization of an acute       nonformulary ostomy and urological supplies
  psychiatric crisis                                 (those not listed on our soft goods formulary for
                                                     your condition) if they would otherwise be
• Psychiatric observation for an acute
                                                     covered and the Medical Group determines that
  psychiatric crisis
                                                     they are Medically Necessary as described in
                                                     “Medical Group authorization procedure for
Note: Outpatient drugs, supplies, and
                                                     certain referrals” under “Getting a Referral” in
supplements are not covered under this “Mental
                                                     the “How to Obtain Services” section.
Health Services” section (instead, refer to the
“Outpatient Prescription Drugs, Supplies, and
                                                     Ostomy and urological supplies exclusion
Supplements” section in this “Benefits,
Copayments, and Coinsurance” section).               • Comfort, convenience, or luxury equipment or
                                                       features



100
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Outpatient Imaging, Laboratory, and                 • Ultraviolet light treatments: no charge
Special Procedures
                                                    Note: Services related to diagnosis and treatment
We cover the following Services at the
                                                    of infertility are not covered under this
Copayment or Coinsurance indicated only when
                                                    “Outpatient Imaging, Laboratory, and Special
prescribed as part of care covered under other
                                                    Procedures” section (instead, refer to the
parts of this “Benefits, Copayments, and
                                                    “Infertility Services” section).
Coinsurance” section:
• Diagnostic and therapeutic imaging, such as       Outpatient Prescription Drugs,
  X-rays, mammograms, and ultrasound:               Supplies, and Supplements
  no charge except that certain imaging
  procedures are covered at a $10 Copayment         We cover outpatient drugs, supplies, and
  per procedure if they are provided in an          supplements specified in this “Outpatient
  outpatient or ambulatory surgery center or in a   Prescription Drugs, Supplies, and Supplements”




                                                                                                        Part Two − Senior Advantage
  hospital operating room, or if they are           section if all of the following are true:
  provided in any setting and a licensed staff      • The item is prescribed either (a) by a Plan
  member monitors your vital signs as you             Physician, or (b) by a dentist or a Non–Plan
  regain sensation after receiving drugs to           Physician in the following circumstances
  reduce sensation or to minimize discomfort          unless a Plan Physician determines that the
• Magnetic resonance imaging (MRI), computed          item is not Medically Necessary or is for a
  tomography (CT), and positron emission              sexual dysfunction disorder:
  tomography (PET): no charge                         ♦ a Non–Plan Physician prescribes the item

• Nuclear medicine: no charge                            after the Medical Group authorizes a written
                                                         referral to a Non–Plan Physician (in accord
• Laboratory tests (including screening tests for        with “Medical Group authorization
  diabetes, cardiovascular disease, cervical             procedure for certain referrals” in the “How
  cancer, and HPV, and tests for specific genetic        to Obtain Services” section) and the item is
  disorders for which genetic counseling is              covered as part of that referral
  available): no charge
                                                      ♦ a Non–Plan Physician prescribes the item in
• Routine preventive retinal photography                 conjunction with covered Emergency Care,
  screenings: no charge                                  Post-Stabilization Care, or Out-of-Area
• All other diagnostic procedures provided by            Urgent Care described in the “Emergency,
  Plan Providers who are not physicians (such as         Post-Stabilization, and Urgent Care from
  electrocardiograms and                                 Non–Plan Providers” section
  electroencephalograms): no charge except that       ♦ a dentist prescribes the drug for dental care
  certain diagnostic procedures are covered at      • The item meets the requirements of our
  a $10 Copayment per procedure if they are           applicable drug formulary guidelines (our
  provided in an outpatient or ambulatory             Medicare Part D formulary or our formulary
  surgery center or in a hospital operating room,     applicable to non-Part D items)
  or if they are provided in any setting and a
  licensed staff member monitors your vital         • You obtain the item from a Plan Pharmacy or
  signs as you regain sensation after receiving       our mail-order service, except as otherwise
  drugs to reduce sensation or to minimize            described under “Certain items from Non–Plan
  discomfort                                          Pharmacies” in this “Outpatient Prescription
                                                      Drugs, Supplies, and Supplements” section.
• Radiation therapy: no charge                        Please refer to our Kaiser Permanente


                                                                                                  101
  Medicare Part D Pharmacy Directory for the          Part D. Therefore, payments for these drugs do
  locations of Plan Pharmacies in your area. Plan     not count toward reaching the Part D
  Pharmacies can change without notice and if a       catastrophic coverage level.
  pharmacy is no longer a Plan Pharmacy, you        • For Medicare Part D covered drugs, the
  must obtain covered items from another Plan         following are additional situations when a
  Pharmacy, except as otherwise described             Part D drug may be covered:
  under “Certain items from Non–Plan
                                                      ♦ If you are traveling outside your Home
  Pharmacies” in this “Outpatient Prescription
                                                         Region’s Service Area, but in the United
  Drugs, Supplies, and Supplements” section
                                                         States and its territories, and you become ill
                                                         or run out of your covered Part D
Obtaining refills by mail
                                                         prescription drugs. We will cover
Most refills are available through our mail-order        prescriptions that are filled at a Non–Plan
service, but there are some restrictions. A Plan         Pharmacy according to our Medicare Part D
Pharmacy, our Kaiser Permanente Medicare                 formulary guidelines
Part D Pharmacy Directory, or our Web site at
                                                      ♦ If you are unable to obtain a covered drug
kp.org/rxrefill can give you more information
                                                         in a timely manner inside your Home
about obtaining refills through our mail-order
                                                         Region’s Service Area because there is no
service. Please check with your local Plan
                                                         Plan Pharmacy within a reasonable driving
Pharmacy if you have a question about whether
                                                         distance that provides 24 hour service. We
or not your prescription can be mailed. Items
                                                         may not cover your prescription if a
available through our mail-order service are
                                                         reasonable person could have purchased the
subject to change at any time without notice.
                                                         drug at a Plan Pharmacy during normal
                                                         business hours
Certain items from Non–Plan Pharmacies
                                                    • If you are trying to fill a prescription for a drug
Generally, we only cover drugs filled at a
                                                      that is not regularly stocked at an accessible
Non–Plan Pharmacy in limited, nonroutine
                                                      Plan Pharmacy or available through our mail
circumstances when a Plan Pharmacy is not
                                                      order pharmacy (including high-cost drugs)
available. Below are the situations when we may
cover prescriptions filled at a Non–Plan
                                                    Payment and reimbursement. If you go to a
Pharmacy. Before you fill your prescription in
                                                    Non–Plan Pharmacy for the reasons listed, you
these situations, call our Member Service Call
                                                    may have to pay the full cost (rather than paying
Center to see if there is a Plan Pharmacy in
                                                    just your Copayment or Coinsurance) when you
your area where you can fill your prescription.
                                                    fill your prescription. You may ask us to
                                                    reimburse you for our share of the cost by
• The drug is related to covered Emergency          submitting a request for reimbursement. If we
  Care, Post-Stabilization Care, or Out-of-Area     pay for the drugs you obtained from a Non–Plan
  Urgent Care, described in the “Emergency,         Pharmacy you may still pay more for your drugs
  Post-Stabilization, and Urgent Care from Non–     than what you would have paid if you had gone
  Plan Providers” section. Note: Prescription       to a Plan Pharmacy because you may be
  drugs prescribed and provided outside of the      responsible for paying the difference between
  United States and its territories as part of      Plan Pharmacy Charges and the price that the
  covered Emergency Care or Urgent Care are         Non–Plan Pharmacy charged you.
  covered up to a 30-day supply in a 30-day
  period. These drugs are covered under Part C
  benefits, and are not covered under Medicare

102
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Medicare Part D drugs                                catastrophic coverage level Copayments that
Medicare Part D covers most outpatient               apply for the calendar year. We will notify you in
prescription drugs if they are sold in the United    advance of any change to your coverage.
States and approved for sale by the federal Food
and Drug Administration. We cover Medicare           The amounts you paid for Medicare Part D drugs
Part D drugs in accord with our Medicare Part D      are computed by adding up the following:
formulary guidelines. Please refer to “Medicare      • The amounts you paid for Medicare Part D
Part D formulary” in this “Outpatient Prescription     drugs we covered in the calendar year under
Drugs, Supplies, and Supplements” section for          this and any other Kaiser Permanente Senior
more information about this formulary.                 Advantage with Part D evidence of coverage
                                                     • If you had previous Medicare Part D coverage
Copayment and Coinsurance for Medicare                 from another organization, that organization’s
Part D drugs. Unless you reach the catastrophic        calculation of the amount you paid under that




                                                                                                          Part Two − Senior Advantage
coverage level in a calendar year, you will pay        coverage for Medicare Part D drugs during the
the following Copayments and Coinsurance for           calendar year (including amounts you paid
covered Medicare Part D drugs:                         toward a Medicare Part D drug deductible)
• Generic drugs: a $5 Copayment for up to a
  100-day supply                                     In order for a Part D drug to count toward the
• For brand-name drugs and specialty drugs:          catastrophic coverage level, it must either be a
  a $15 Copayment for up to a 100-day supply         covered drug or a drug that would have been
                                                     covered if you had met your deductible or you
• Emergency contraceptive pills: no charge
                                                     were not in a coverage level in which you had to
• The following insulin-administration devices       pay full price (your previous coverage may or
  at a $5 Copayment: needles, syringes, alcohol      may not consider drugs to be covered in those
  swabs, and gauze                                   circumstances). If you obtain noncovered
                                                     Medicare Part D drugs from us, you will pay the
Catastrophic coverage level. All Medicare            full price of the drug and that amount does not
Prescription Drug Plans include catastrophic         count toward the catastrophic coverage level.
coverage for people with high drug costs. In order
to qualify for catastrophic coverage, you must       Also, when the following individuals or
spend $4,550 out-of-pocket during 2010. When         organizations pay your costs for such drugs, these
the total amount you have paid for your              payments will count toward your out-of-pocket
Copayments or Coinsurance reaches $4,550, you        costs and will help you qualify for catastrophic
will qualify for catastrophic coverage, and then     coverage:
you will pay the following for the remainder of      • Family members or other individuals
2010:
                                                     • Medicare programs that provide extra help
• a $3 Copayment per prescription for insulin
                                                       with prescription drug coverage
  administration devices and generic drugs
                                                     • Most charities or charitable organizations that
• a $10 Copayment per prescription for brand-
                                                       pay Copayment or Coinsurance on your
  name drugs and specialty drugs
                                                       behalf. Please note that if the charity is
• Emergency contraceptive pills: no charge             established, run, or controlled by your current
                                                       or former employer or union, the payments
Note: Each year effective on January 1, CMS            usually will not count toward your
may change coverage level thresholds and               out-of-pocket costs


                                                                                                   103
Note: if you have coverage from a third party        Not all drugs are covered by our Plan. In some
(e.g., insurance plans government-funded health      cases, the law prohibits Medicare coverage of
programs or workers compensation) that pay a         certain types of drugs under Part D coverage.
part of or all of your out-of-pocket costs, you
must let us know.                                    Each year, we send you an updated Part D
                                                     formulary so you can find out what drugs are on
Keeping track of Medicare Part D drugs. The          our Part D formulary. You can get updated
Explanation of Benefits (EOB) is a document you      information about the drugs our Plan covers by
will get for each month you use your Part D          visiting our Web site at kp.org/seniormedrx.
prescription drug coverage. The EOB will tell        You may also call our Member Service Call
you the total amount you have spent on your          Center to find out if your drug is on the formulary
prescription drugs and the total amount we have      or to request an updated copy of our formulary.
paid for your prescription drugs. An “Explanation
of Benefits.” is also available upon request from    We may make certain changes to our formulary
our Member Service Call Center.                      during the year. Changes in the formulary may
                                                     affect which drugs are covered and how much
Extra help for covered Medicare Part D drugs.        you will pay when filling your prescription. The
Medicare provides “extra help” to pay                kinds of formulary changes we may make
prescription drug costs for people who have          include:
limited income and resources. Resources include      • Adding or removing drugs from the formulary
your savings and stocks, but not your home or
car. If you qualify, you will get help paying for    • Adding prior authorizations, quantity limits, or
any Medicare drug plan's monthly premium and           step-therapy restrictions on a drug
Copayments or Coinsurance for Part D drugs. If       • Moving a drug to a higher or lower
you qualify, this extra help will count toward         Copayment or Coinsurance tier
your out-of-pocket costs. Please see “Extra help
with drug plan expenses” in the “Premiums,           If we remove drugs from the formulary, or add
Eligibility and Enrollment” section for more         prior authorizations, quantity limits, or step
information.                                         therapy restrictions on a drug, or move a drug to a
                                                     higher Copayment or Coinsurance tier, and you
Medicare Part D drug formulary                       are taking the drug affected by the change, you
Our Medicare Part D drug formulary is a list of      will be permitted to continue receiving that drug
the drugs that we cover under your Part D drug       at the same level of Copayment or Coinsurance
coverage. We will generally cover the drugs          for the remainder of the calendar year. However,
listed in our formulary as long as the drug is       if a brand-name drug is replaced with a new
Medically Necessary, the prescription is filled at   generic drug, or our formulary is changed as a
a Plan Pharmacy, and other coverage rules are        result of new information on a drug's safety or
followed. For certain prescription drugs, we have    effectiveness, you may be affected by this
additional requirements for coverage or limits on    change. We will notify you of the change at least
our coverage. These requirements and limits are      60 days before the date that the change becomes
described under “Utilization management” in this     effective or provide you with a 60-day supply at
“Outpatient Prescription Drugs, Supplies, and        the Plan Pharmacy. This will give you an
Supplements” section.                                opportunity to work with your physician to
                                                     switch to a different drug that we cover or request
The drugs on the formulary are selected by our       an exception. (If a drug is removed from our
Plan with the help of a team of Plan Providers.      formulary because the drug has been recalled

104
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


from the pharmacies, we will not give 60 days         the catastrophic coverage level. A Medicare
notice before removing the drug from the              Prescription Drug Plan can't cover a drug under
formulary. Instead, we will remove the drug           Medicare Part D in the following situations:
immediately and notify members taking the drug        • The drug would be covered under Medicare
about the change as soon as possible.)                  Part A or Part B

If your prescription isn’t listed on your copy of     • Drug purchased outside the United States and
our formulary you should first check the                its territories
formulary on our Web site which we update             • Off-label uses (meaning for uses other than
when there is a change. In addition, you may            those indicated on a drug's label as approved
contact our Member Service Call Center to be            by the Food and Drug Administration) of a
sure it isn't covered. If Member Services confirms      prescription drug, except in cases where the
that we don't cover your drug, you have two             use is supported by certain reference-book
options:                                                citations. Congress specifically listed the




                                                                                                             Part Two − Senior Advantage
                                                        reference books that list whether the off-label
                                                        use would be permitted. (These reference
• You may ask your Plan Physician if you can
                                                        books are American Hospital Formulary
  switch to another drug that is covered by us
                                                        Service Drug Information, the DRUGDEX
• You or your Plan Physician may ask us to              Information System, and USPDI or its
  make an exception (a type of coverage                 successor.) If the use is not supported by one
  determination) to cover your drug. See Section        of these reference books, known as
  “Requests for Services or Payment,                    compendia, then the drug is considered a non–
  Complaints, and Medicare Appeal Procedures”           Part D drug and cannot be covered by under
  for more information on how to request an             Medicare Part D coverage
  exception
                                                      In addition, by law, certain types of drugs or
Transition policy. If you recently joined our         categories of drugs are not covered under
Plan, you may be able to get, during the first 90     Medicare Part D. These drugs include:
days of your membership, a temporary supply of
a drug you were taking when you joined our Plan       • Nonprescription drugs (or over-the-counter
if it isn't on our formulary. Current members may       drugs)
also be affected by changes in our formulary          • Drugs when used to promote fertility
from one year to the next. Members should talk        • Drugs when used for the symptomatic relief of
to their Plan Physicians to decide if they should       cough or colds
switch to a different drug that we cover or request
a Part D formulary exception in order to get          • Outpatient drugs for which the manufacturer
coverage for the drug. Please refer to our              seeks to require that associated tests or
formulary or our Web site kp.org/seniormedrx            monitoring services be purchased exclusively
for more information about our Part D transition        from the manufacturer as a condition of sale
coverage.                                             • Drugs such as Viagra, Cialis, Levitra, and
                                                        Caverject when used for the treatment of
Medicare Part D exclusions (non-Part D                  sexual or erectile dysfunction
drugs). By law, certain types of drugs are not        • Drugs when used for treatment of anorexia,
covered by Medicare Part D. If a drug is not            weight loss, or weight gain
covered by Medicare Part D, any amounts you
pay for that drug will not count toward reaching      • Drugs when used for cosmetic purposes or to
                                                        promote hair growth

                                                                                                       105
• Prescription vitamins and mineral products,          • Clotting factors you give yourself by injection
  except prenatal vitamins and fluoride                  if you have hemophilia
  preparations                                         • Immunosuppressive drugs, if Medicare paid
• Barbiturates and Benzodiazepines                       for the transplant (or a group plan was required
                                                         to pay before Medicare paid for it)
Note: In addition to the coverage provided under       • Injectable osteoporosis drugs, if you are
this Medicare Part D plan, you also have                 homebound, have a bone fracture that a doctor
coverage for non–Part D drugs described under            certifies was related to post-menopausal
“Outpatient drugs covered by Medicare Part B”            osteoporosis, and cannot self-administer the
and “Other outpatient drugs, supplies, and               drug
supplements” in this “Outpatient Prescription
                                                       • Antigens
Drugs, Supplies, and Supplements” section. If a
drug is not covered under Medicare Part D,             • Certain oral anticancer drugs and antinausea
please refer to those headings for information           drugs
about your non–Part D drug coverage.                   • Certain drugs for home dialysis, including
                                                         heparin, the antidote for heparin when
Other prescription drug coverage. We will                Medically Necessary, topical anesthetics, and
send you a Medicare secondary payor survey so            erythropoisis-stimulating agents
that we can know what other health care or drug
                                                       • Intravenous Immune Globulin for the home
coverage you have besides our Plan. Medicare
                                                         treatment of primary immune deficiency
requires us to collect this information from you,
                                                         diseases
so when you get the survey, please fill it out and
send it back. If you have additional health care or
drug coverage, you must provide that information       Copayment for Medicare Part B drugs. You
to our Plan. The information you provide helps us      pay the following for Medicare Part B drugs:
calculate how much you and others have paid for        • Generic drugs: a $5 Copayment for up to a
your prescription drugs. In addition, if you lose or     100-day supply
gain additional health care or prescription drug
coverage, please call our Member Service Call          • Brand-name drugs specialty drugs and
Center to update your membership records.                compounded products: a $15 Copayment for
                                                         up to a 100-day supply
Outpatient drugs covered by Medicare Part B
                                                       Note: Home infusion drugs covered by Medicare
In addition to Medicare Part D drugs, we also
                                                       Part B are not described under this section (refer
cover the limited number of outpatient
                                                       to “Certain IV drugs, supplies, and
prescription drugs that are covered by Medicare
                                                       supplements”).
Part B in accord with our other drug formulary
applicable to non- Part D items. The following
                                                       Other outpatient drugs, supplies, and
are the types of drugs that Medicare Part B
covers:                                                supplements
                                                       If a drug, supply, or supplement is not covered by
• Drugs that usually aren't self-administered by
                                                       Medicare Part B or D, we cover the following
  the patient and are injected while you are
                                                       additional items in accord with our non- Part D
  getting physician services
                                                       drug formulary:
• Drugs you take using durable medical
                                                       • Drugs for which a prescription is required by
  equipment (such as nebulizers) that was
                                                         law that are not covered by Medicare Part B or
  prescribed by a Plan Physician

106
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  D. We also cover certain drugs that do not         • Diaphragms and cervical caps:
  require a prescription by law if they are listed     a $15 Copayment per item
  on our drug formulary applicable to non-           • Diabetes urine-testing supplies: no charge for
  Part D items. Note: Certain tobacco-cessation        up to a 100-day supply
  drugs if not covered by Medicare Part D are
  covered only if you participate in a behavioral
                                                     Non- Part D drug formulary. Our non- Part D
  intervention program approved by the Medical
                                                     drug formulary includes the list of drugs that
  Group
                                                     have been approved by our Pharmacy and
• Diaphragms and cervical caps                       Therapeutics Committee for our Members. Our
• Disposable needles and syringes needed for         Pharmacy and Therapeutics Committee, which is
  injecting covered drugs, pen delivery devices,     primarily composed of Plan Physicians, selects
  and visual aids required to ensure proper          drugs for the drug formulary based on a number
  dosage (except eyewear), that are not covered      of factors, including safety and effectiveness as




                                                                                                           Part Two − Senior Advantage
  by Medicare Part B or D                            determined from a review of medical literature.
                                                     The Pharmacy and Therapeutics Committee
• Inhaler spacers needed to inhale covered drugs
                                                     meets quarterly to consider additions and
• Ketone test strips and sugar or acetone test       deletions based on new information or drugs that
  tablets or tapes for diabetes urine testing        become available. If you would like to request a
• Continuity non-Part D drugs: If this DF/EOC        copy of our non- Part D drug formulary, please
  is amended to exclude a non-Part D drug that       call our Member Service Call Center. Note: The
  we have been covering and providing to you         presence of a drug on our drug formulary does
  under this DF/EOC, we will continue to             not necessarily mean that your Plan Physician
  provide the non-Part D drug if a prescription is   will prescribe it for a particular medical
  required by law and a Plan Physician               condition.
  continues to prescribe the drug for the same
  condition and for a use approved by the FDA        Our drug formulary guidelines allow you to
                                                     obtain nonformulary prescription drugs (those not
Copayments and Coinsurance for other                 listed on our drug formulary for your condition)
outpatient drugs, supplies, and supplements.         if they would otherwise be covered and a Plan
The Copayments and Coinsurance for these items       Physician determines that they are Medically
are as follows:                                      Necessary. If you disagree with your Plan
                                                     Physician’s determination that a nonformulary
• Generic items: a $5 Copayment for up to a
                                                     prescription drug is not Medically Necessary, you
  100-day supply
                                                     may file an appeal as described in the “Requests
• Brand-name items, specialty drugs, and             for Services or Payment, Complaints, and
  compounded products: a $15 Copayment for           Medicare Appeal Procedures” section. Also, our
  up to a 100-day supply                             non- Part D formulary guidelines may require
• Amino acid–modified products used to treat         you to participate in a behavioral intervention
  congenital errors of amino acid metabolism         program approved by the Medical Group for
  (such as phenylketonuria) and elemental            specific conditions and you may be required to
  dietary enteral formula when used as a primary     pay for the program.
  therapy for regional enteritis: no charge for up
  to a 30-day supply                                 Certain IV drugs, supplies, and supplements
• Continuity drugs: 50 percent Coinsurance for       We cover certain self-administered IV drugs,
  up to a 30-day supply in a 30-day period           fluids, additives, and nutrients that require


                                                                                                     107
specific types of parenteral-infusion (such as an    If you are selected to join a medication therapy
IV or intraspinal-infusion) at no charge for up to   management program, we will send you
a 30-day supply. In addition, we cover the           information about the specific program, including
supplies and equipment required for the              information about how to access the program.
administration of these drugs at no charge.
                                                     ID card at Plan Pharmacies
Drug utilization review                              You must present your Kaiser Permanente ID
We conduct drug utilization reviews to make sure     card when obtaining covered items from Plan
that you are getting safe and appropriate care.      Pharmacies that are not owned and operated by
These reviews are especially important if you        Kaiser Permanente. If you do not have your ID
have more than one doctor who prescribes your        card, the Plan Pharmacy may require you to pay
medications. We conduct drug utilization reviews     Charges for your covered items, and you will
each time you fill a prescription and on a regular   have to file a claim for reimbursement as
basis by reviewing our records. During these         described in the “Requests for Services or
reviews, we look for medication problems such        Payment, Complaints, and Medicare Appeal
as:                                                  Procedures” section.
• Possible medication errors
                                                     Notes:
• Duplicate drugs that are unnecessary because
  you are taking another drug to treat the same      • If Charges for a covered item are less than the
  medical condition                                    Copayment, you will pay the lesser amount
• Drugs that are inappropriate because of your       • Durable medical equipment used to administer
  age or gender                                        drugs, such as diabetes insulin pumps (and
                                                       their supplies), and diabetes blood-testing
• Possible harmful interactions between drugs
                                                       equipment (and their supplies) are not covered
  you are taking
                                                       under this “Outpatient Prescription Drugs,
• Drug allergies                                       Supplies, and Supplements” section (instead,
• Drug dosage errors                                   refer to “Durable Medical Equipment for
                                                       Home Use” in this “Benefits, Copayments, and
If we identify a medication problem during our         Coinsurance” section)
drug utilization review, we will work with your      • Except for vaccines covered by Medicare Part
doctor to correct the problem.                         D, drugs administered to you in a Plan
                                                       Medical Office or during home visits are not
Medication therapy management programs                 covered under this “Outpatient Prescription
We offer medication therapy management                 Drugs, Supplies, and Supplements” section
programs at no additional cost to Members who          (instead, refer to the “Outpatient Care” section
have multiple medical conditions, who are taking       in this “Benefits, Copayments, and
many prescription drugs, and who have high drug        Coinsurance” section)
costs. These programs were developed for us by a     • Drugs covered during a covered stay in a Plan
team of pharmacists and doctors. We use these          Hospital or Skilled Nursing Facility are not
medication therapy management programs to              covered under this “Outpatient Prescription
help us provide better care for our members. For       Drugs, Supplies, and Supplements” section
example, these programs help us make sure that         (instead, refer to the “Hospital Inpatient Care”
you are using appropriate drugs to treat your          and “Skilled Nursing Facility Care” sections in
medical conditions and help us identify possible
medication errors.
108
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  this “Benefits, Copayments, and Coinsurance”         episodic drugs prescribed for the treatment of
  section)                                             sexual dysfunction up to a maximum of 8
                                                       doses in any 30-day period, 16 doses in any
Outpatient prescription drugs, supplies, and           60-day period, or 27 doses in any 100-day
supplements limitations                                period. Also, when there is a shortage of a
Day supply limit. Plan Physicians determine the        drug in the marketplace and the amount of
amount of a drug or other item that is Medically       available supplies, we may reduce the quantity
Necessary for a particular day supply for you.         of the drug dispensed accordingly and charge
Upon payment of the Copayments and                     one Copayment
Coinsurance specified in this “Outpatient            • Generic substitution: When there is a generic
Prescription Drugs, Supplies, and Supplements”         version of a brand-name drug available, Plan
section, you will receive the supply prescribed up     Pharmacies will automatically give you the
to a 100-day supply in a 100-day period.               generic version, unless your Plan Physician
                                                       has specifically requested a formulary




                                                                                                           Part Two − Senior Advantage
However, the Plan Pharmacy may reduce the day
supply dispensed to a 30-day supply in any 30-         exception because it is Medically Necessary
day period at the Copayment or Coinsurance             for you to receive the brand-name drug instead
listed in this “Outpatient Prescription Drugs,         of the formulary alternative
Supplies, and Supplements” section if the Plan
Pharmacy determines that the drug is in limited      Outpatient prescription drugs, supplies, and
supply in the market or a 31-day supply in any       supplements exclusions
31-day period if the item is dispensed by a long
                                                     • Any requested packaging (such as dose
term care facility’s pharmacy. Plan Pharmacies
                                                       packaging) other than the dispensing
may also limit the quantity dispensed as
                                                       pharmacy’s standard packaging
described under “Utilization management.” If
you wish to receive more than the covered day        • Compounded products unless the active
supply limit, then the additional amount is not        ingredient in the compounded product is listed
covered and you must pay Charges for any               on one of our drug formularies
prescribed quantities that exceed the day supply     • Drugs when prescribed to shorten the duration
limit. The amount you pay for noncovered drugs         of the common cold
does not count toward reaching the catastrophic
coverage level.                                      Prosthetic and Orthotic Devices

Utilization management. For certain items, we        Inside your Home Region’s Service Area, we
have additional coverage requirements and limits     cover the devices specified in this “Prosthetic and
that help promote effective drug use and help us     Orthotic Devices” section if they are in general
control drug plan costs. Examples of these           use, intended for repeated use, primarily and
utilization management tools are:                    customarily used for medical purposes, and
                                                     generally not useful to a person who is not ill or
• Quantity limits: The Plan Pharmacy may             injured. However, if you were enrolled in Senior
  reduce the day supply dispensed at the             Advantage on December 31, 1998, and lived
  Copayment or Coinsurance specified in this         outside your Home Region’s Service Area, but
  “Outpatient Drugs, Supplies, and                   inside California, and you continue to live at the
  Supplements” section to a 30-day supply in         same address, we will cover prosthetic and
  any 30-day period for specific drugs. Your
                                                     orthotic devices described in this section.
  Plan Pharmacy can tell you if a drug you take
  is one of these drugs. In addition, we cover


                                                                                                    109
Coverage is limited to the standard device that      • Enteral formula for Members who require tube
adequately meets your medical needs.                   feeding in accord with Medicare guidelines
                                                     • Prostheses to replace all or part of an external
We select the provider or vendor that will furnish     facial body part that has been removed or
the covered device. Coverage includes fitting and      impaired as a result of disease, injury, or
adjustment of these devices, their repair or           congenital defect
replacement, and Services to determine whether
you need a prosthetic or orthotic device. If we do   • Other covered prosthetic and orthotic devices:
not cover the device, we will try to help you find     ♦ prosthetic devices required to replace all or
facilities where you may obtain what you need at         part of an organ or extremity, but only
a reasonable price.                                      if they also replace the function of the organ
                                                         or extremity
Internally implanted devices                           ♦ orthotic devices required to support or
We cover at no charge internal devices                   correct a defective body part in accord with
implanted during covered surgery, such as                Medicare guidelines
pacemakers, intraocular lenses, cochlear               ♦ special footwear when custom made for
implants, osseointegrated external hearing               foot disfigurement due to disease, injury, or
devices, and hip joints that are covered by              developmental disability
Medicare.
                                                     Note:
External devices                                     • Eyeglasses and contact lenses are not covered
We cover the following external prosthetic and         under this “Prosthetic and Orthotic Devices”
orthotic devices, including repair and                 section (instead, refer to the “Vision Services”
replacement of covered devices, at no charge:          in this “Benefits, Copayments, and
• Prosthetics and orthotics that are covered by        Coinsurance” section).
  Medicare. These include braces, prosthetic         • Hearing aids (other than internally implanted
  shoes, artificial limbs, and therapeutic             devices described in this section) are not
  footwear for severe diabetes-related foot            covered under this “Prosthetic and Orthotic
  disease in accord with Medicare guidelines           Devices” section (instead, refer to the
• Prosthetic devices and installation accessories      “Hearing Services” in this “Benefits,
  to restore a method of speaking following the        Copayments, and Coinsurance” section).
  removal of all or part of the larynx (this
  coverage does not include electronic voice-        Prosthetic and orthotic devices exclusions
  producing machines, which are not prosthetic       • Dental appliances
  devices)
                                                     • Except as otherwise described above in this
• Prostheses needed after a Medically Necessary        “Prosthetic and Orthotic Devices” section,
  mastectomy, including custom-made                    nonrigid supplies not covered by Medicare,
  prostheses when Medically Necessary                  such as elastic stockings and wigs
• Podiatric devices (including footwear) to          • Comfort, convenience, or luxury equipment or
  prevent or treat diabetes-related complications      features
  when prescribed by a Plan Physician or by a
  Plan Provider who is a podiatrist                  • Shoes or arch supports, even if custom-made,
                                                       except footwear described above in this
• Compression burn garments and lymphedema             “Prosthetic and Orthotic Devices” section for
  wraps and garments

110
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  diabetes-related complications and foot             • Prosthetics and orthotics (instead, refer to the
  disfigurement                                         “Prosthetic and Orthotic Devices” section in
                                                        this “Benefits, Copayments, and Coinsurance”
Reconstructive Surgery                                  section)
We cover reconstructive surgery to correct or
                                                      Reconstructive surgery exclusions
repair abnormal structures of the body caused by
congenital defects, developmental abnormalities,      • Surgery that, in the judgment of a Plan
trauma, infection, tumors, or disease, if a Plan        Physician specializing in reconstructive
Physician determines that it is necessary to            surgery, offers only a minimal improvement in
improve function, or create a normal appearance,        appearance
to the extent possible.                               • Surgery that is performed to alter or reshape
                                                        normal structures of the body in order to
Also, following Medically Necessary removal of          improve appearance




                                                                                                           Part Two − Senior Advantage
all or part of a breast, we cover reconstruction of
the breast, surgery and reconstruction of the other
                                                      Religious Nonmedical Health Care
breast to produce a symmetrical appearance, and
                                                      Institution Services
treatment of physical complications, including
lymphedemas.                                          Care in a Medicare-certified Religious
                                                      Nonmedical Health Care Institution (RNHCI) is
You pay the following for covered reconstructive      covered by our Plan under certain conditions.
surgery Services:                                     Covered Services in an RNHCI are limited to
• Office visits: a $10 Copayment per visit            nonreligious aspects of care. To be eligible for
                                                      covered Services in a RNHCI, you must have a
• Outpatient surgery: a $10 Copayment                 medical condition that would allow you to
  per procedure                                       receive inpatient hospital or Skilled Nursing
• Hospital inpatient care (including room and         Facility care. You may get Services furnished in
  board, drugs, and Plan Physician Services):         the home, but only items and Services ordinarily
  no charge                                           furnished by home health agencies that are not
                                                      RNHCIs. In addition, you must sign a legal
Note: The following Services are not covered          document that says you are conscientiously
under this “Reconstructive Surgery” section:          opposed to the acceptance of “nonexcepted”
• Outpatient laboratory and imaging Services          medical treatment. (“Excepted” medical
  (instead, refer to the “Outpatient Imaging,         treatment is medical care or treatment that you
  Laboratory, and Special Procedures” section in      receive involuntarily or that is required under
  this “Benefits, Copayments, and Coinsurance”        federal, state, or local law. “Nonexcepted”
  section)                                            medical treatment is any other medical care or
                                                      treatment.) Your stay in the RNHCI is not
• Outpatient prescription drugs (instead, refer to    covered by us unless you obtain authorization
  the “Outpatient Prescription Drugs, Supplies,       (approval) in advance from us.
  and Supplements” section in this “Benefits,
  Copayments, and Coinsurance” section)               Note: Covered Services are subject to the same
• Outpatient administered drugs (instead, refer       limitations Copayments and Coinsurance
  to the “Outpatient Care” section in this            required for Services provided by Plan Providers
  “Benefits, Copayments, and Coinsurance”             as described in this “Benefits, Copayments, and
  section)                                            Coinsurance” section.


                                                                                                    111
Skilled Nursing Facility Care                        • Medical supplies
Inside your Home Region’s Service Area, we           • Physical, occupational, and speech therapy in
cover at no charge up to 100 days per benefit          accord with Medicare guidelines
period of skilled inpatient Services in a Plan       • Respiratory therapy
Skilled Nursing Facility and in accord with
Medicare guidelines. The skilled inpatient           Note: Outpatient imaging, laboratory, and special
Services must be customarily provided by a           procedures are not covered under this section
Skilled Nursing Facility, and above the level of     (instead, refer to “Outpatient Imaging,
custodial or intermediate care.                      Laboratory, and Special Procedures” in this
                                                     “Benefits, Copayments, and Coinsurance”
A benefit period begins on the date you are          section).
admitted to a hospital or Skilled Nursing Facility
at a skilled level of care (defined in accord with   Non–Plan Skilled Nursing Facility care
Medicare guidelines). A benefit period ends on
                                                     Generally, you will get your Skilled Nursing
the date you have not been an inpatient in a
                                                     Facility care from Plan Facilities. However,
hospital or Skilled Nursing Facility, receiving a
                                                     under certain conditions listed below, you may be
skilled level of care, for 60 consecutive days. A
                                                     able to pay your Copayment or Coinsurance for a
new benefit period can begin only after any
                                                     facility that isn't a Plan provider, if the facility
existing benefit period ends. A prior three-day
                                                     accepts our Plan's amounts for payment.
stay in an acute care hospital is not required.
Note: If your Copayment or Coinsurance changes       • A nursing home or continuing care retirement
during a benefit period, you will continue to pay      community where you were living right before
the previous Copayment or Coinsurance amount           you went to the hospital (as long as it provides
until a new benefit period begins.                     Skilled Nursing Facility care)
                                                     • A Skilled Nursing Facility where your spouse
We cover the following Services:                       is living at the time you leave the hospital
• Physician and nursing Services
                                                     Transplant Services
• Room and board
• Drugs prescribed by a Plan Physician as part       We cover transplants of organs, tissue, or bone
  of your plan of care in the Plan Skilled           marrow in accord with Medicare guidelines and
  Nursing Facility in accord with our drug           if the Medical Group provides a written referral
  formulary guidelines if they are administered      for care to a transplant facility as described in
  to you in the Plan Skilled Nursing Facility by     “Medical Group authorization procedure for
  medical personnel                                  certain referrals” under “Getting a Referral” in
                                                     the “How to Obtain Services” section.
• Durable medical equipment in accord with our
  DME formulary and Medicare guidelines              After the referral to a transplant facility, the
  if Skilled Nursing Facilities ordinarily furnish   following applies:
  the equipment
                                                     • If either the Medical Group or the referral
• Imaging and laboratory Services that Skilled         facility determines that you do not satisfy its
  Nursing Facilities ordinarily provide                respective criteria for a transplant, we will
• Medical social services                              only cover Services you receive before that
• Blood, blood products, and their                     determination is made
  administration

112
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


• Health Plan, Plan Hospitals, the Medical            Vision Services
  Group, and Plan Physicians are not responsible
                                                      We cover the Services listed below at Plan
  for finding, furnishing, or ensuring the
                                                      Medical Offices or Plan Optical Sales Offices
  availability of an organ, tissue, or bone
                                                      when prescribed by a Plan Physician or by a Plan
  marrow donor
                                                      Provider who is an optometrist.
• In accord with our guidelines for Services for
  living transplant donors, we provide certain        Eye exams
  donation-related Services for a donor, or an
                                                      Routine preventive refraction exams to determine
  individual identified by the Medical Group as
                                                      the need for vision correction and to provide a
  a potential donor, whether or not the donor is a
                                                      prescription for eyeglass lenses and glaucoma
  Member. These Services must be directly
                                                      screenings in accord with Medicare guidelines:
  related to a covered transplant for you, which
                                                      a $10 Copayment per visit.
  may include certain Services for harvesting the




                                                                                                             Part Two − Senior Advantage
  organ, tissue, or bone marrow and for
                                                      Optical Services
  treatment of complications. Our guidelines for
  donor Services are available by calling our         Eyeglasses and contact lenses. We provide a
  Member Service Call Center                          $175 Allowance toward the purchase price of any
                                                      or all of the following every 24 months:
For covered transplant Services that you receive,     • Eyeglass lenses when a Plan Provider puts the
you will pay the Copayments and Coinsurance             lenses into a frame
you would pay if the Services were not related        • Eyeglass frames when a Plan Provider puts
to a transplant.                                        two lenses (at least one of which must have
                                                        refractive value) into the frame
We provide or pay for donation-related Services
for actual or potential donors (whether or not they   • Contact lenses, fitting, and dispensing
are Members) in accord with our guidelines for
donor Services at no charge.                          We will not provide the Allowance if we have
                                                      provided an Allowance toward (or otherwise
Note: The following Services are not covered          covered) lenses or frames within the previous 24
under this “Transplant Services” section:             months.

• Outpatient laboratory and imaging Services          The Allowance can only be used at the initial
  (instead, refer to “Outpatient Imaging,             point of sale. If you do not use all of your
  Laboratory, and Special Procedures” in this         Allowance at the initial point of sale, you cannot
  “Benefits, Copayments, and Coinsurance”             use it later.
  section)
• Outpatient prescription drugs (instead, refer to    If you have a change in prescription of at least .50
  “Outpatient Prescription Drugs, Supplies, and       diopter in one or both eyes within 12 months of
  Supplements” in this “Benefits, Copayments,         the initial point of sale, we will provide an
  and Coinsurance” section)                           Allowance toward the purchase price of a
• Outpatient administered drugs (instead, refer       replacement eyeglass lens (or contact lens, fitting,
  to “Outpatient Care” in this “Benefits,             and dispensing). The Allowance for these
  Copayments, and Coinsurance” section)               replacement lenses is $60 for single vision
                                                      eyeglass lenses or contact lenses, fitting, and
                                                      dispensing and $90 for multifocal eyeglass
                                                      lenses.


                                                                                                     113
Special contact lenses. We cover the following      toward the purchase price of eyeglass lenses,
special contact lenses:                             frames, and contact lenses (including fitting and
• Up to two Medically Necessary contact lenses,     dispensing). It can be used only at the initial point
  fitting, and dispensing per eye every 12          of sale. If you do not use all of your Allowance at
  months (including lenses we covered under         the initial point of sale, you cannot use it later.
  any other evidence of coverage offered by         Also, the Allowance for each cataract surgery
  your Group) to treat aniridia (missing iris):     must be used before a later cataract surgery.
  no charge                                         There is only one Allowance of $150 after any
                                                    cataract surgery.
• Up to six Medically Necessary aphakic contact
  lenses, fitting, and dispensing per eye per
                                                    Note: Services related to the eye or vision, other
  calendar year (including lenses we covered
                                                    than those described in this section, are not
  under any other evidence of coverage offered
                                                    covered under this “Vision Services” section
  by your Group) to treat aphakia (absence of
                                                    (instead, refer to the applicable heading in this
  the crystalline lens of the eye): no charge
                                                    “Benefits, Copayments, and Coinsurance”
• If contact lenses will provide a significant      section).
  improvement in your vision not obtainable
  with eyeglass lenses, we cover either one pair    Vision Services exclusions
  of contact lenses or an initial supply of
  disposable contact lenses every 24 months at      • Industrial frames
  no charge. When we cover these special            • Lenses and sunglasses without refractive value
  contact lenses, you cannot use the Allowance        except that this exclusion does not apply to
  mentioned under “Eyeglasses and contact             any of the following:
  lenses” for another 24 months. However, if the      ♦ a clear balance lens if only one eye needs
  combination of special contact lenses and             correction
  eyeglasses will provide a significant
                                                      ♦ tinted lenses except when Medically
  improvement in your vision not obtainable
                                                        Necessary to treat macular degeneration or
  with special contact lenses alone, you can use
                                                        retinitis pigmentosa
  that Allowance toward the purchase of the
  eyeglasses if we have not covered lenses or       • Replacement of lost, broken, or damaged
  frames within the previous 24 months. If you        lenses or frames
  have a change in prescription of at least .50     • Lens adornment, such as engraving, faceting,
  diopter in one or both eyes, we will cover          or jeweling
  special contact lens replacements, including
                                                    • Low-vision devices
  fitting and dispensing for the eye(s) that have
  the .50 diopter change                            • Non-prescription products, such as eyeglass
                                                      holders, eyeglass cases, and repair kits
Eyeglasses and contact lenses following
cataract surgery. In accord with Medicare
guidelines, we provide a $150 Allowance after
each cataract surgery. You can use the Allowance




114
       Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


EXCLUSIONS, LIMITATIONS, COORDINATION OF BENEFITS,
AND REDUCTIONS

Exclusions                                             impaired as a result of disease, injury, or
                                                       congenital defect.
The Services listed in this “Exclusions” section
are excluded from coverage. These exclusions
                                                       Custodial care
apply to all Services that would otherwise be
covered under this DF/EOC. Additional                  Custodial care means assistance with activities of
exclusions that apply only to a particular benefit     daily living (for example: walking, getting in and
are listed in the description of that benefit in the   out of bed, bathing, dressing, feeding, toileting,
“Benefits, Copayments, and Coinsurance”                and taking medicine), or care that can be
section.                                               performed safely and effectively by people who,




                                                                                                             Part Two − Senior Advantage
                                                       in order to provide the care, do not require
Certain exams and Services                             medical licenses or certificates or the presence of
                                                       a supervising licensed nurse.
Physical examinations and other Services
(1) required for obtaining or maintaining
                                                       This exclusion does not apply to Services covered
employment or participation in employee
                                                       under “Hospice Care” in the “Benefits,
programs, (2) required for insurance or licensing,
                                                       Copayments, and Coinsurance” section for
or (3) on court order or required for parole or
                                                       Members who do not have Part A.
probation. This exclusion does not apply if a Plan
Physician determines that the Services are
                                                       Dental care
Medically Necessary.
                                                       Dental care and dental X-rays, such as dental
Conception by artificial means                         Services following accidental injury to teeth,
                                                       dental appliances, dental implants, orthodontia,
Except for artificial insemination covered under
                                                       and dental Services resulting from medical
“Infertility Services” in the “Benefits,
                                                       treatment such as surgery on the jawbone and
Copayments, and Coinsurance” section, all other
                                                       radiation treatment, except for Services covered
Services related to conception by artificial means,
                                                       by Medicare or under “Dental Services for
such as ovum transplants, gamete intrafallopian
                                                       Radiation Treatment and Dental Anesthesia” in
transfer (GIFT), semen and eggs (and Services
                                                       the “Benefits, Copayments, and Coinsurance”
related to their procurement and storage), in vitro
                                                       section.
fertilization (IVF), and zygote intrafallopian
transfer (ZIFT).
                                                       Disposable supplies
Cosmetic Services                                      Disposable supplies for home use, such as
                                                       bandages, gauze, tape, antiseptics, dressings,
Services that are intended primarily to change or
                                                       Ace-type bandages, and diapers, underpads, and
maintain your appearance, except for Services
                                                       other incontinence supplies.
covered under “Reconstructive Surgery” and the
following prosthetic devices covered under
                                                       This exclusion does not apply to disposable
“Prosthetic and Orthotic Devices” in the
                                                       supplies covered by Medicare or under “Durable
“Benefits, Copayments, and Coinsurance”
                                                       Medical Equipment for Home Use,” “Home
section: prostheses needed after a mastectomy,
                                                       Health Care,” “Hospice Care,” “Ostomy and
and prostheses to replace all or part of an external
                                                       Urological Supplies,” and “Outpatient
facial body part that has been removed or

                                                                                                      115
Prescription Drugs, Supplies, and Supplements”        This exclusion does not apply to any of the
in the “Benefits, Copayments, and Coinsurance”        following:
section.                                              • Amino acid–modified products and elemental
                                                        dietary enteral formula covered under
Experimental or investigational Services                “Outpatient Prescription Drugs, Supplies, and
A Service is experimental or investigational if         Supplements” in the “Benefits, Copayments,
we, in consultation with the Medical Group,             and Coinsurance” section
determine that one of the following is true:          • Enteral formula covered under “Prosthetic and
• Generally accepted medical standards do not           Orthotic Devices” in the “Benefits,
  recognize it as safe and effective for treating       Copayments, and Coinsurance” section
  the condition in question (even if it has been
  authorized by law for use in testing or other       Routine foot care Services
  studies on human patients)                          Routine foot care, except for Medically
• It requires government approval that has not        Necessary Services covered by Medicare.
  been obtained when the Service is to be
  provided                                            Services not approved by the FDA
                                                      Drugs, supplements, tests, vaccines, devices,
Note: For information about clinical trials           radioactive materials, and any other Services that
covered by Original Medicare, refer to “Special       by law require federal Food and Drug
Note about Clinical Trials” in the “Benefits,         Administration (FDA) approval in order to be
Copayments, and Coinsurance” section.                 sold in the U.S, but are not approved by the FDA.
                                                      This exclusion applies to Services provided
Eye surgery                                           anywhere, even outside the U.S., unless the
Services related to eye surgery or                    Services are covered under the “Emergency,
orthokeratologic Services for the purpose of          Post-Stabilization, and Urgent Care from
correcting refractive defects such as myopia,         Non-Plan Providers” section.
hyperopia, or astigmatism.
                                                      Services not covered by Medicare
Hair loss or growth treatment                         Services that aren't reasonable and necessary,
Services for the promotion, prevention or other       according to the standards of the Original
treatment of hair loss or hair growth.                Medicare plan, unless these Services are
                                                      otherwise listed in this DF/EOC as a covered
Intermediate care                                     Service.
Care in a licensed intermediate care facility. This
exclusion does not apply to Services covered          Services related to a noncovered Service
under “Hospice Care” in the “Benefits,                When a Service is not covered, all Services
Copayments, and Coinsurance” section for              related to the noncovered Service are excluded,
Members who do not have Part A.                       except for Services we would otherwise cover to
                                                      treat complications of the noncovered Service or
Oral nutrition                                        if covered by Medicare.
Outpatient oral nutrition, such as dietary
supplements, herbal supplements, weight loss          Surrogacy
aids, formulas, and food.                             Services for anyone in connection with a
                                                      surrogacy arrangement, except for otherwise-

116
       Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


covered Services provided to a Member who is a          Coordination of Benefits
surrogate. Please refer to “Surrogacy
                                                        If you have other medical or dental coverage, it is
arrangements” under “Reductions” in this
                                                        important to use your other coverage in
“Exclusions, Limitations, Coordination of
                                                        combination with your coverage as a Senior
Benefits, and Reductions” section for
                                                        Advantage Member to pay for the care you
information, including your obligation to
                                                        receive. This is called “coordination of benefits”
reimburse us for any Services we cover.
                                                        because it involves coordinating all of the health
                                                        benefits that are available to you. Using all of the
Transgender surgery
                                                        coverage you have helps keep the cost of health
                                                        care more affordable for everyone.
Travel and lodging expenses
Travel and lodging expenses, except that in some        You must tell us if you have other health care
situations if the Medical Group refers you to a         coverage, and let us know whenever there are any




                                                                                                               Part Two − Senior Advantage
Non–Plan Provider as described in “Medical              changes in your additional coverage. The types of
Group authorization procedure for certain               additional coverage that you might have include
referrals” under “Getting a Referral” in the “How       the following:
to Obtain Services” section, we may pay certain         • Coverage that you have from an employer’s
expenses that we preauthorize in accord with our          group health care coverage for employees or
travel and lodging guidelines. Our travel and             retirees, either through yourself or your spouse
lodging guidelines are available from our
Member Service Call Center.                             • Coverage that you have under workers’
                                                          compensation because of a job-related illness
Limitations                                               or injury, or under the Federal Black Lung
                                                          Program
We will do our best to provide or arrange for our
                                                        • Coverage you have for an accident where no-
Members’ health care needs in the event of
                                                          fault insurance or liability insurance is
unusual circumstances that delay or render
                                                          involved
impractical the provision of Services under this
DF/EOC, such as major disaster, epidemic, war,          • Coverage you have through Medicaid
riot, civil insurrection, disability of a large share   • Coverage you have through the “TRICARE
of personnel at a Plan Facility, complete or partial      for Life” program (veteran’s benefits)
destruction of facilities, and labor disputes. Under
                                                        • Coverage you have for dental insurance or
these extreme circumstances, if you have an
                                                          prescription drugs
Emergency Medical Condition, go to the nearest
hospital as described under “Emergency Care” in         • “Continuation coverage” you have through
the “Emergency, Post-Stabilization, and Urgent            COBRA (COBRA is a law that requires
Care from Non–Plan Providers” section, and we             employers with 20 or more employees to let
will provide coverage and reimbursement as                employees and their dependents keep their
described in that section.                                group health coverage for a time after they
                                                          leave their group health plan under certain
Additional limitations that apply only to a               conditions)
particular benefit are listed in the description of
that benefit in the “Benefits, Copayments, and          When you have additional health care coverage,
Coinsurance” section.                                   how we coordinate your benefits as a Senior
                                                        Advantage Member with your benefits from your
                                                        other coverage depends on your situation. With


                                                                                                        117
coordination of benefits, you will often get your      employer, and when we cover any such Services,
care as usual from Plan Providers, and the other       we may recover the value of the Services from
coverage you have will simply help pay for the         the employer.
care you receive. In other situations, such as
benefits that we don’t cover, you may get your         Government agency responsibility
care outside of our Plan directly through your         For any Services that the law requires be
other coverage.                                        provided only by or received only from a
                                                       government agency, we will not pay the
In general, the coverage that pays its share of        government agency, and when we cover any such
your bills first is called the “primary payer.” Then   Services we may recover the value of the
the other company or companies that are involved       Services from the government agency.
(called the “secondary payers”) each pay their
share of what is left of your bills. Often your        Injuries or illnesses alleged to be caused by third
other coverage will settle its share of payment        parties
directly with us and you will not have to be
                                                       If you obtain a judgment or settlement from or on
involved. However, if payment owed to us is sent
                                                       behalf of a third party who allegedly caused an
directly to you, you are required under Medicare
                                                       injury or illness for which you received covered
law to give this payment to us. When you have
                                                       Services, you must pay us Charges for those
additional coverage, whether we pay first or
                                                       Services, except that the amount you must pay
second, or at all, depends on what type or types
                                                       will not exceed the maximum amount allowed
of additional coverage you have and the rules that
                                                       under California Civil Code Section 3040. Note:
apply to your situation. Many of these rules are
                                                       This “Injuries or illnesses alleged to be caused by
set by Medicare. Some of them take into account
                                                       third parties” section does not affect your
whether you have a disability or have end-stage
                                                       obligation to pay Copayments and Coinsurance
renal disease, or how many employees are
                                                       for these Services, but we will credit any such
covered by an employer’s group plan.
                                                       payments toward the amount you must pay us
                                                       under this paragraph.
If you have additional health coverage, please
call our Member Service Call Center to find out
                                                       To the extent permitted or required by law, we
which rules apply to your situation, and how
                                                       have the option of becoming subrogated to all
payment will be handled. Also, the Medicare
                                                       claims, causes of action, and other rights you may
program has written a booklet with general
                                                       have against a third party or an insurer,
information about what happens when people
                                                       government program, or other source of coverage
with Medicare have additional coverage. It’s
                                                       for monetary damages, compensation, or
called Medicare and Other Health Benefits: Your
                                                       indemnification on account of the injury or illness
Guide to Who Pays First. You can get a copy by
                                                       allegedly caused by the third party. We will be so
calling toll free 800-MEDICARE (800-633-4227)
                                                       subrogated as of the time we mail or deliver a
(TTY users call 877-486-2048) 24 hours a day,
                                                       written notice of our exercise of this option to
seven days a week, or by visiting the
                                                       you or your attorney, but we will be subrogated
www.medicare.gov Web site.
                                                       only to the extent of the total of Charges for the
                                                       relevant Services.
Reductions
                                                       To secure our rights, we will have a lien on the
Employer responsibility
                                                       proceeds of any judgment or settlement you or
For any Services that the law requires an              we obtain against a third party. The proceeds of
employer to provide, we will not pay the

118
       Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


any judgment or settlement that you or we obtain         the claim against the third party. We may assign
shall first be applied to satisfy our lien, regardless   our rights to enforce our liens and other rights.
of whether the total amount of the proceeds is
less than the actual losses and damages you              Medicare law may apply with respect to Services
incurred.                                                covered by Medicare.

Within 30 days after submitting or filing a claim        Medicare benefits
or legal action against a third party, you must          As a Senior Advantage Member, you receive all
send written notice of the claim or legal action to:     Medicare-covered benefits through us (except as
   For Northern California Members:                      otherwise noted in this DF/EOC) and these
   Northern California Third Party Liability             benefits are not duplicated.
   Supervisor
   Kaiser Foundation Health Plan, Inc.                   Surrogacy arrangements




                                                                                                             Part Two − Senior Advantage
   Special Recovery Unit                                 If you enter into a surrogacy arrangement, you
   Parsons East, Second Floor                            must pay us Charges for covered Services you
   393 E. Walnut St.                                     receive related to conception, pregnancy, or
   Pasadena, CA 91188                                    delivery in connection with that arrangement
                                                         (“Surrogacy Health Services”), except that the
   For Southern California Members:                      amount you must pay will not exceed the
   Southern California Third Party Liability             compensation you are entitled to receive under
   Supervisor                                            the surrogacy arrangement. A surrogacy
   Kaiser Foundation Health Plan, Inc.                   arrangement is one in which a woman agrees to
   Special Recovery Unit                                 become pregnant and to surrender the baby to
   Parsons East, Second Floor                            another person or persons who intend to raise the
   393 E. Walnut St.                                     child. Note: This “Surrogacy arrangements”
   Pasadena, CA 91188                                    section does not affect your obligation to pay
                                                         Copayments and Coinsurance for these Services,
In order for us to determine the existence of any        but we will credit any such payments toward the
rights we may have and to satisfy those rights,          amount you must pay us under this paragraph.
you must complete and send us all consents,
releases, authorizations, assignments, and other         By accepting Surrogacy Health Services, you
documents, including lien forms directing your           automatically assign to us your right to receive
attorney, the third party, and the third party’s         payments that are payable to you or your chosen
liability insurer to pay us directly. You may not        payee under the surrogacy arrangement,
agree to waive, release, or reduce our rights under      regardless of whether those payments are
this provision without our prior, written consent.       characterized as being for medical expenses. To
                                                         secure our rights, we will also have a lien on
If your estate, parent, guardian, or conservator         those payments. Those payments shall first be
asserts a claim against a third party based on your      applied to satisfy our lien. The assignment and
injury or illness, your estate, parent, guardian, or     our lien will not exceed the total amount of your
conservator and any settlement or judgment               obligation to us under the preceding paragraph.
recovered by the estate, parent, guardian, or
conservator shall be subject to our liens and other      Within 30 days after entering into a surrogacy
rights to the same extent as if you had asserted         arrangement, you must send written notice of the
                                                         arrangement, including the names and addresses


                                                                                                       119
of the other parties to the arrangement, and a        U.S. Department of Veterans Affairs
copy of any contracts or other documents              For any Services for conditions arising from
explaining the arrangement, to:                       military service that the law requires the
                                                      Department of Veterans Affairs to provide, we
    Surrogacy Third Party Liability Supervisor        will not pay the Department of Veterans Affairs,
    Kaiser Foundation Health Plan, Inc.               and when we cover any such Services we may
    Special Recovery Unit                             recover the value of the Services from the
    Parsons East, Second Floor                        Department of Veterans Affairs.
    393 E. Walnut St.
    Pasadena, CA 91188                                Workers’ compensation or employer’s liability
                                                      benefits
You must complete and send us all consents,
                                                      You may be eligible for payments or other
releases, authorizations, lien forms, and other
                                                      benefits, including amounts received as a
documents that are reasonably necessary for us to
                                                      settlement (collectively referred to as “Financial
determine the existence of any rights we may
                                                      Benefit”), under workers’ compensation or
have under this “Surrogacy arrangements”
                                                      employer’s liability law. We will provide covered
section and to satisfy those rights. You may not
                                                      Services even if it is unclear whether you are
agree to waive, release, or reduce our rights under
                                                      entitled to a Financial Benefit, but we may
this provision without our prior, written consent.
                                                      recover the value of any covered Services from
                                                      the following sources:
If your estate, parent, guardian, or conservator
asserts a claim against a third party based on the    • From any source providing a Financial Benefit
surrogacy arrangement, your estate, parent,             or from whom a Financial Benefit is due
guardian, or conservator and any settlement or        • From you, to the extent that a Financial
judgment recovered by the estate, parent,               Benefit is provided or payable or would have
guardian, or conservator shall be subject to our        been required to be provided or payable if you
liens and other rights to the same extent as if you     had diligently sought to establish your rights to
had asserted the claim against the third party. We      the Financial Benefit under any workers’
may assign our rights to enforce our liens and          compensation or employer’s liability law
other rights.




120
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


GRIEVANCES

We are committed to providing you with quality        • Rude behavior by Plan Providers or staff
care and with a timely response to your concerns.
If you have a complaint or issue, you may file a      • Cleanliness or condition of Plan Facilities
grievance with us in certain cases. This section
describes the complaints and issues that are          This grievance procedure does not apply to the
subject to this grievance procedure and how to        following complaints or issues, instead please
file a grievance. The grievance procedure applies     refer to the “Requests for Services or Payment,
to any complaint or issue unless it involves a        Complaints, and Medicare Appeal Procedures”
request for an initial determination, an appeal, or   section:
a complaint about certain Services ending too         • Problems related to the coverage we provide
soon as described in the “Requests for Services or      for Part C Services or Part D drugs (including




                                                                                                            Part Two − Senior Advantage
Payment, Complaints, and Medicare Appeal                requests for Services you have not received
Procedures” section.                                    and payment or reimbursement for Services
                                                        you have already received)
If you have one of the following types of             • Complaints about having to leave the hospital
problems and want to make a complaint, you may          too soon
file a grievance:
                                                      • Complaints about having Skilled Nursing
• Problems with the quality of the Services you         Facility (SNF), Home Health Agency (HHA),
  receive                                               or Comprehensive Outpatient Rehabilitation
• If you feel that you are being encouraged to          Facility (CORF) Services ending too soon,
  leave (disenroll from) our Plan                       instead refer to the “Initial Determinations” in
• If you disagree with our decision not to give         the “Requests for Services or Payment,
  you a “fast” initial determination or appeal          Complaints, and Medicare Appeal Procedures”
  (see “Fast grievances” in this “Grievances”           section to learn how to resolve these issues
  section for more information)
                                                      Special note about hospice care
• We don't forward your case to the Independent
  Review Entity (IRE) if we do not give you our       If you have Medicare Part A, your hospice care is
  appeal decision on time                             covered by Original Medicare and it is not
                                                      covered under this DF/EOC. Therefore, any
• For drugs you have already received, you
                                                      grievances related to the coverage of hospice care
  believe that you waited too long for the
                                                      must be resolved directly with Medicare and not
  prescription to be filled
                                                      through any grievance or appeal procedure
• Problems with how long you had to wait for          discussed in this DF/EOC. Medicare grievance
  Services that you have already received,            and appeal procedures are described in the
  including appointments and your wait time on        Medicare handbook Medicare & You, which is
  the phone, in the waiting room, or in the exam      available from your local Social Security office,
  room                                                or by calling toll free 800-MEDICARE
• You believe our notices and other written           (800-633-4227) (TTY users call 877-486-2048)
  materials are hard to understand                    24 hours a day, seven days a week. If you do not
                                                      have Medicare Part A, Original Medicare does
• Problems with the Service you receive from
                                                      not cover hospice care. Instead, we will provide
  Member Services
                                                      hospice care and any grievances related to


                                                                                                      121
hospice care are subject to this “Grievances”         “representative.” You may name a relative,
section.                                              friend, lawyer, advocate, doctor, or anyone else to
                                                      act for you. Other persons may already be
Filing a Grievance                                    authorized by the Court, or in accordance with
                                                      state law, to act for you. If you want someone to
If you have a complaint or issue, you or your
                                                      act for you who is not already authorized by the
representative may call the phone number listed
                                                      Court or under state law, then you and that person
in the “Helpful Phone Numbers and Resources”
                                                      must sign and date a statement that gives the
section under “Contact information for
                                                      person legal permission to be your representative.
grievances, organization determinations,
                                                      To learn how to name your representative, you
coverage determinations, and appeals.” We will
                                                      may call our Member Service Call Center.
try to resolve your complaint or issue over the
phone. If you ask for a written response, file a
                                                      Fast Grievances
written grievance, or your complaint is related to
quality of care, we will respond in writing to you.   As described in the “Requests for Services or
If we cannot resolve your complaint or issue          Payment, Complaints, and Medicare Appeal
over the phone, we have a formal procedure to         Procedures” section, you may request a “fast
review your complaints and issues, which we           grievance,” which means we will answer your
call a “grievance procedure.”                         grievance within 24 hours in the following
                                                      situations:
To file a grievance you or your representative        • We deny your request to expedite an initial
should call, fax, or write us at the numbers or         determination related to a Service that you
address listed in the “Helpful Phone Numbers and        have not yet received
Resources” section under “Contact information         • We deny your request to expedite your
for grievances, organization determinations,            Medicare appeal
coverage determinations, and appeals.” Please see
“Fast grievances” below for information about         • We decide to extend the time we need to make
fast grievances.                                        a standard or expedited initial determination or
                                                        appeal
You must submit your grievance within 60 days
of the event or incident. We must address your        Quality Improvement Organization (QIO)
grievance as quickly as your case requires based      You may complain about the quality of care
on your health status, but no later than 30 days      received under Medicare, including care during a
after receiving your complaint. We may extend         hospital stay. You may complain to us using the
the time frame by up to 14 days if you ask for the    grievance process, to the Quality Improvement
extension, or if we justify a need for additional     Organization (QIO), or both. If you file with the
information and the delay is in your best interest.   QIO, we must help the QIO resolve the
If we deny your grievance in whole or in part, our    complaint.
written decision will explain why we denied it,
and will tell you about any dispute resolution        To file a complaint with the local Quality
options you may have (for example, binding            Improvement Organization, you should write to
arbitration).                                         Health Services Advisory Group, Inc., Attn:
                                                      Beneficiary Protection, 5201 W. Kennedy
Who may file a grievance                              Boulevard, Suite 900, Tampa, Florida
You or someone you name may file a grievance.         33609-1822 (fax number 415-677-2185), or call
The person you name would be your                     toll free 800-841-1602, 24 hours a day, seven
                                                      days a week (TTY users call 800-881-5980).
122
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


CalPERS Administrative Review                         CalPERS administrative review process
If you do not achieve resolution of your              CalPERS staff may conduct an administrative
complaint through the dispute resolution              review of your dispute if we deny your grievance
processes described in this “Grievances” section      as described in this section or your Medicare
and the “Requests for Services or Payment,            Appeal described in the “Request for Services or
Complaints, and Medicare Appeal Procedures”           Payment, Complaints, and Medicare Appeal
section, you have additional dispute resolution       Procedures” section. However, your written
options, depending on the nature of the               request must be submitted to CalPERS within 30
complaint.                                            days of the date of our denial letter.

Eligibility                                           If the dispute remains unresolved during the
                                                      administrative review process, the matter may
Issues of eligibility must be referred directly to
                                                      proceed to an Administrative Hearing. During the
CalPERS. Contact the CalPERS Office of




                                                                                                           Part Two − Senior Advantage
                                                      hearing, evidence and testimony will be presented
Employer and Member Health Services at P.O.
                                                      to an Administrative Law Judge. As an
Box 942714, Sacramento, CA 94229-2714, fax
                                                      alternative to this hearing, you may have recourse
number 916-795-1277, or telephone the CalPERS
                                                      through binding arbitration (or Small Claims
Customer Service and Education Division at
                                                      Court if applicable). However, you must choose
888-CalPERS (888-225-7377).
                                                      between the Administrative Hearing and binding
                                                      arbitration (or Small Claims Court if applicable).
Coverage
                                                      You may not take the same issue through both
A coverage issue concerns the denial of Services      procedures. You may withdraw your request from
substantially based on a finding that the provision   CalPERS at any time, and proceed to binding
of a particular Service is excluded as a covered      arbitration (or Small Claims Court if applicable).
benefit under this DF/EOC. It does not include a
Plan Provider’s decision about a disputed             To request an administrative review, please
Service.                                              contact CalPERS Office of Employer and
                                                      Member Health Services at P.O. Box 942714,
If you are dissatisfied with the outcome of the       Sacramento, CA 94229-2714, fax number
grievance process described in this “Grievances”      916-795-1277, or telephone the CalPERS
section or the Medicare appeal process described      Customer Service and Education Division toll
in the “Requests for Services or Payment,             free at 888-CalPERS (888-225-7377).
Complaints, and Medicare Appeal Procedures”
section, you may request an administrative            Binding Arbitration
review through the CalPERS Board of
Administration. As an alternative to the              For all claims subject to this “Binding
administrative review process, you may submit         Arbitration” section, both Claimants and
the matter to binding arbitration (or Small Claims    Respondents give up the right to a jury or court
Court if applicable). However, you must choose        trial and accept the use of binding arbitration.
between the CalPERS administrative process and        Insofar as this “Binding Arbitration” section
arbitration (or Small Claims Court if applicable).    applies to claims asserted by Kaiser Permanente
You may not take the issue through both               Parties, it shall apply retroactively to all
procedures.                                           unresolved claims that accrued before the
                                                      effective date of this DF/EOC. Such retroactive
                                                      application shall be binding only on the Kaiser
                                                      Permanente Parties.


                                                                                                     123
Scope of Arbitration                                   • A Member
Any dispute shall be submitted to binding              • A Member’s heir, relative, or personal
arbitration if all of the following requirements are     representative
met:
                                                       • Any person claiming that a duty to him or her
• The claim arises from or is related to an              arises from a Member’s relationship to one or
  alleged violation of any duty incident to or           more Kaiser Permanente Parties
  arising out of or relating to this DF/EOC or a
  Member Party’s relationship to Kaiser                “Kaiser Permanente Parties” include:
  Foundation Health Plan, Inc. (Health Plan),
                                                       • Kaiser Foundation Health Plan, Inc. (Health
  including any claim for medical or hospital
                                                         Plan)
  malpractice (a claim that medical services
  were unnecessary or unauthorized or were             • Kaiser Foundation Hospitals (KFH)
  improperly, negligently, or incompetently            • KP Cal, LLC (KP Cal)
  rendered), for premises liability, or relating to
                                                       • The Permanente Medical Group, Inc. (TPMG)
  the coverage for, or delivery of, Services,
  irrespective of the legal theories upon which        • Southern California Permanente Medical
  the claim is asserted                                  Group (SCPMG)
• The claim is asserted by one or more Member          • The Permanente Federation, LLC
  Parties against one or more Kaiser Permanente        • The Permanente Company, LLC
  Parties or by one or more Kaiser Permanente
  Parties against one or more Member Parties           • Any KFH, TPMG, or SCPMG physician

• The claim is not within the jurisdiction of the      • Any individual or organization whose contract
  Small Claims Court                                     with any of the organizations identified above
                                                         requires arbitration of claims brought by one
• If your Group must comply with the Employee            or more Member Parties
  Retirement Income Security Act (ERISA)
  requirements, the claim is not a benefit-related     • Any employee or agent of any of the foregoing
  request that constitutes a “benefit claim” in
  Section 502(a)(1)(B) of ERISA. Note: Benefit         “Claimant” refers to a Member Party or a Kaiser
  claims under this section of ERISA are               Permanente Party who asserts a claim as
  excluded from this binding arbitration               described above. “Respondent” refers to a
  requirement only until such time as the United       Member Party or a Kaiser Permanente Party
  States Department of Labor regulation                against whom a claim is asserted.
  prohibiting mandatory binding arbitration of
  this category of claim (29 CFR 2560.503-             Initiating Arbitration
  1(c)(4)) is modified, amended, repealed,             Claimants shall initiate arbitration by serving a
  superseded, or otherwise found to be invalid.        Demand for Arbitration. The Demand for
  If this occurs, these claims will automatically      Arbitration shall include the basis of the claim
  become subject to mandatory binding                  against the Respondents; the amount of damages
  arbitration without further notice                   the Claimants seek in the arbitration; the names,
• The claim is not subject to a Medicare appeal        addresses, and telephone numbers of the
  procedure                                            Claimants and their attorney, if any; and the
                                                       names of all Respondents. Claimants shall
As referred to in this “Binding Arbitration”           include all claims against Respondents that are
section, “Member Parties” include:                     based on the same incident, transaction, or related
                                                       circumstances in the Demand for Arbitration.
124
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Serving Demand for Arbitration                         Number of Arbitrators
Health Plan, KFH, KP Cal, TPMG, SCPMG, The             The number of Arbitrators may affect the
Permanente Federation, LLC, and The                    Claimant’s responsibility for paying the neutral
Permanente Company, LLC, shall be served with          arbitrator’s fees and expenses.
a Demand for Arbitration by mailing the Demand
for Arbitration addressed to that Respondent in        If the Demand for Arbitration seeks total
care of:                                               damages of $200,000 or less, the dispute shall be
                                                       heard and determined by one neutral arbitrator,
   For Northern California Members:
                                                       unless the parties otherwise agree in writing that
   Kaiser Foundation Health Plan, Inc.
                                                       the arbitration shall be heard by two party
   Legal Department
                                                       arbitrators and one neutral arbitrator. The neutral
   1950 Franklin St., 17th Floor
                                                       arbitrator shall not have authority to award
   Oakland, CA 94612
                                                       monetary damages that are greater than $200,000.




                                                                                                              Part Two − Senior Advantage
   For Southern California Members:
                                                       If the Demand for Arbitration seeks total
   Kaiser Foundation Health Plan, Inc.
                                                       damages of more than $200,000, the dispute shall
   Legal Department
                                                       be heard and determined by one neutral arbitrator
   393 E. Walnut St.
                                                       and two party arbitrators, one jointly appointed
   Pasadena, CA 91188
                                                       by all Claimants and one jointly appointed by all
                                                       Respondents. Parties who are entitled to select a
Service on that Respondent shall be deemed
                                                       party arbitrator may agree to waive this right. If
completed when received. All other Respondents,
                                                       all parties agree, these arbitrations will be heard
including individuals, must be served as required
                                                       by a single neutral arbitrator.
by the California Code of Civil Procedure for a
civil action.
                                                       Payment of Arbitrators’ Fees and Expenses
Filing Fee                                             Health Plan will pay the fees and expenses of the
                                                       neutral arbitrator under certain conditions as set
The Claimants shall pay a single, nonrefundable,
                                                       forth in the Rules for Kaiser Permanente Member
filing fee of $150 per arbitration payable to
                                                       Arbitrations Overseen by the Office of the
“Arbitration Account” regardless of the number
                                                       Independent Administrator (“Rules of
of claims asserted in the Demand for Arbitration
                                                       Procedure”). In all other arbitrations, the fees and
or the number of Claimants or Respondents
                                                       expenses of the neutral arbitrator shall be paid
named in the Demand for Arbitration.
                                                       one-half by the Claimants and one-half by the
                                                       Respondents.
Any Claimant who claims extreme hardship may
request that the Office of the Independent
                                                       If the parties select party arbitrators, Claimants
Administrator waive the filing fee and the neutral
                                                       shall be responsible for paying the fees and
arbitrator’s fees and expenses. A Claimant who
                                                       expenses of their party arbitrator and
seeks such waivers shall complete the Fee Waiver
                                                       Respondents shall be responsible for paying the
Form and submit it to the Office of the
                                                       fees and expenses of their party arbitrator.
Independent Administrator and simultaneously
serve it upon the Respondents. The Fee Waiver
                                                       Costs
Form sets forth the criteria for waiving fees and is
available by calling our Member Service Call           Except for the aforementioned fees and expenses
Center.                                                of the neutral arbitrator, and except as otherwise
                                                       mandated by laws that apply to arbitrations under


                                                                                                       125
this “Binding Arbitration” section, each party        incident, transaction, or related circumstances
shall bear the party’s own attorneys’ fees, witness   involved in the claim. A claim may be dismissed
fees, and other expenses incurred in prosecuting      on other grounds by the neutral arbitrator based
or defending against a claim regardless of the        on a showing of a good cause. If a party fails to
nature of the claim or outcome of the arbitration.    attend the arbitration hearing after being given
                                                      due notice thereof, the neutral arbitrator may
Rules of Procedure                                    proceed to determine the controversy in the
Arbitrations shall be conducted according to the      party’s absence.
Rules of Procedure developed by the Office of
the Independent Administrator in consultation         The California Medical Injury Compensation
with Kaiser Permanente and the Arbitration            Reform Act of 1975 (including any amendments
Oversight Board. Copies of the Rules of               thereto), including sections establishing the right
Procedure may be obtained from our Member             to introduce evidence of any insurance or
Service Call Center.                                  disability benefit payment to the patient, the
                                                      limitation on recovery for noneconomic losses,
General Provisions                                    and the right to have an award for future damages
                                                      conformed to periodic payments, shall apply to
A claim shall be waived and forever barred if
                                                      any claims for professional negligence or any
(1) on the date the Demand for Arbitration of the
                                                      other claims as permitted or required by law.
claim is served, the claim, if asserted in a civil
action, would be barred as to the Respondents
                                                      Arbitrations shall be governed by this “Binding
served by the applicable statute of limitations,
                                                      Arbitration” section, Section 2 of the Federal
(2) Claimants fail to pursue the arbitration claim
                                                      Arbitration Act, and the California Code of Civil
in accord with the Rules of Procedure with
                                                      Procedure provisions relating to arbitration that
reasonable diligence, or (3) the arbitration
                                                      are in effect at the time the statute is applied,
hearing is not commenced within five years after
                                                      together with the Rules of Procedure, to the
the earlier of (a) the date the Demand for
                                                      extent not inconsistent with this “Binding
Arbitration was served in accord with the
                                                      Arbitration” section.
procedures prescribed herein, or (b) the date of
filing of a civil action based upon the same




126
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


REQUESTS FOR SERVICES OR PAYMENT, COMPLAINTS, AND
MEDICARE APPEAL PROCEDURES

This section explains how you ask for coverage        Service or Part D drug you have already received,
of your Part C Services and Part D drug or            you must request an initial determination from
payments in different situations. This section also   our Plan.
explains how to make complaints when you think
you are being asked to leave the hospital too         Initial Determinations
soon, or you think your Skilled Nursing Facility      The initial determination we make is the starting
(SNF), Home Health Agency (HHA), or                   point for dealing with requests you may have
Comprehensive Outpatient Rehabilitation Facility      about covering a Part C Service or Part D drug
(CORF) Services are ending too soon. These            you need, or paying for a Part C Service or Part D
types of requests and complaints are discussed




                                                                                                            Part Two − Senior Advantage
                                                      drug you have already received. Initial decisions
below in Part 1, Part 2, and Part 3.                  about Part C Services are called “organization
                                                      determinations.” Initial decisions about Part D
Other complaints that do not involve the types of     drugs are called “coverage determinations.” With
requests or complaints discussed below in Part 1,     this decision, we explain whether we will provide
Part 2, or Part 3 are considered grievances. You      the Part C Service or Part D drug you are
would file a grievance if you have any type of        requesting, or pay for the Part C Service or Part D
problem with us or one of our Plan Providers that     drug you have already received.
does not relate to coverage for Part C Services
and Part D drugs. For more information about          The following are examples of requests for initial
grievances, see the “Grievances” section.             determinations:

Part 1. Requests for Part C Services and              • You ask us to pay for a prescription drug you
        Part D drugs or payments.                       have received
Part 2. Complaints if you think you are asked         • You ask for a Part D drug that is not on our
        to leave the hospital too soon.                 Plan's list of covered drugs (called a
Part 3. Complaints if you think your Skilled            “formulary”). This is a request for a
        Nursing Facility (SNF), Home Health             “formulary exception.” See “Requests for a
        Agency (HHA), or Comprehensive                  Part D exception” below for more information
        Outpatient Rehabilitation Facility              about the exception process
        (CORF) Services are ending too soon.          • You ask for an exception to our utilization
                                                        management tools, such as dosage limits.
PART 1. Requests for Part C Services                    Requesting an exception to a utilization
and Part D Drugs or Payment                             management tool is a type of formulary
This part explains what you can do if you have          exception. See “Requests for a Part D
problems getting the Part C Services or Part D          exception” below for more information about
drugs you request, or payment (including the            the exceptions process
amount you paid) for a Part C Service or Part D       • You ask us to pay for the cost of a drug you
drug you have already received.                         bought at a Non–Plan Pharmacy. In certain
                                                        circumstances, out-of-network purchases,
If you have problems getting the Part C Services        including drugs provided to you in a
or Part D drugs you need, or payment for a Part C       physician's office, will be covered by our Plan.


                                                                                                     127
  See “Outpatient Prescription Drugs, Supplies,      Your doctor must submit a statement supporting
  and Supplements” in the “Benefits,                 your exception request. In order to help us make
  Copayments, and Coinsurance” section for a         a decision more quickly, the supporting medical
  description of these circumstances                 information from your doctor should be sent to us
• You are not getting Part C Services you want,      with the exception request.
  and you believe that this care is covered by our
  Plan                                               If we approve your exception request, our
                                                     approval is valid for the remainder of the plan
• We will not approve the medical treatment
                                                     year, so long as your doctor continues to
  your doctor or other medical provider wants to
                                                     prescribe the Part D drug for you and it continues
  give you, and you believe that this treatment is
                                                     to be safe for treating your condition. If we deny
  covered by our Plan
                                                     your exception request, you may appeal our
• You are being told that a medical treatment or     decision.
  Service you have been getting will be reduced
  or stopped, and you believe that this could        Note: If we approve your exception request for
  harm your health                                   a Part D non-formulary drug, you cannot
• You have received Part C Services that you         request an exception to the Copayment or
  believe should be covered by our Plan, but we      Coinsurance amount we require you to pay for
  have refused to pay for this care                  the drug.

Requests for a Part D exception                      You may call us at the phone number shown for
                                                     Part D coverage determinations in the “Helpful
A Part D exception is a type of initial
                                                     Phone Numbers and Resources” section under
determination (also called a “coverage
determination”) involving a Part D drug. You or      “Contact information for grievances, organization
                                                     determinations, coverage determinations, and
your doctor may ask us to make an exception to
                                                     appeals.”
our Part D coverage rules in a few situations.
• You may ask us to cover your Part D drug           Who may ask for an initial determination?
  even if it is not on our formulary
                                                     You, your prescribing physician, or someone you
• You may ask us to waive coverage restrictions      name may ask us for an initial determination. The
  or limits on your Part D drug. For example, for    person you name would be your “appointed
  certain Part D drugs, we limit the amount of       representative.” You may name a relative, friend,
  the drug that we will cover. If your Part D        lawyer, advocate, doctor, or anyone else to act for
  drug has a quantity limit, you may ask us to       you. Other persons may already be authorized by
  waive the limit and cover more. See                the Court or in accordance with state law to act
  “Outpatient Prescription Drugs, Supplies, and      for you. If you want someone to act for you who
  Supplements” in the “Benefits, Copayments,         is not already authorized by the Court or under
  and Coinsurance” section to learn more about       state law, then you and that person must sign and
  our additional coverage restrictions or limits     date a statement that gives the person legal
  on certain drugs                                   permission to be your appointed representative. If
                                                     you are requesting Part C Services or Part D
Generally, we will only approve your request for     drugs, this statement must be sent to us at the
an exception if the alternative Part D drugs         address or fax number listed in the “Helpful
included on our Plan formulary would not be as       Phone Numbers and Resources” section under
effective in treating your condition or would        “Contact information for grievances, organization
cause you to have adverse medical effects.

128
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


determinations, coverage determinations, and          supports you in asking for one, and the doctor
appeals.”                                             indicates that waiting for a standard decision
                                                      could seriously harm your health or your ability
Asking for a “standard” or “fast” initial             to function, we will automatically give you a fast
determination. A decision about whether we will       decision.
give you, or pay for, the Part C Service or Part D
drug you are requesting can be a “standard”           If you ask for a fast decision without support
decision that is made within the standard time        from a doctor, we will decide if your health
frame or it can be a “fast” decision that is made     requires a fast decision. If we decide that your
more quickly. A fast decision is also called an       medical condition does not meet the requirements
“expedited” decision.                                 for a fast decision, we will send you a letter
                                                      informing you that if you get a doctor's support
Asking for a standard decision. To ask for a          for a fast review, we will automatically give you
standard decision for a Part C Service or Part D      a fast decision. The letter will also tell you how to




                                                                                                              Part Two − Senior Advantage
drug you, your doctor, or your representative         file a “fast grievance.” You have the right to file a
should call, fax or write us at the numbers or        fast grievance if you disagree with our decision to
address listed in the “Helpful Phone Numbers and      deny your request for a fast review (for more
Resources” section under “Contact information         information about fast grievances, see the
for grievances, organization determinations,          “Grievances” section). If we deny your request
coverage determinations, and appeals” (for an         for a fast initial determination, we will give you a
initial determination about Part D drugs or Part C    standard decision.
Services).
                                                      What happens when you request an initial
Asking for a fast decision. You may ask for a         determination?
fast decision only if you or your doctor believe
                                                      • For a standard initial determination about a
that waiting for a standard decision could
                                                        Part D drug (including a request to pay for
seriously harm your health or your ability to
                                                        a Part D drug that you have already
function. Fast decisions apply only to requests for
                                                        received)
benefits that you have not yet received. You
                                                         Generally, we must give you our decision no
cannot get a fast decision if you are asking us to
                                                         later than 72 hours after we receive your
pay for a Part C Service or Part D drug that you
                                                         request, but we will make it sooner if your
have already received.
                                                         request is for a Part D drug that you have not
                                                         received yet and your health condition
If you are requesting a Part C Service or Part D
                                                         requires us to. However, if your request
drug that you have not yet received, you, your
                                                         involves a request for an exception (including
doctor, or your representative may ask us to give
                                                         a formulary exception, tiering exception, or
you a fast decision by calling, faxing, or writing
                                                         an exception from utilization management
us at the numbers or address listed in the “Helpful
                                                         rules, such as dosage limits), we must give
Phone Numbers and Resources” section under
                                                         you our decision no later than 72 hours after
“Contact information for grievances, organization
                                                         we receive your physician's “supporting
determinations, coverage determinations, and
                                                         statement” explaining why the drug you are
appeals” (for an initial determination about
                                                         asking for is Medically Necessary. If you
Part D drugs or Part C Services).
                                                         have not received an answer from us within
                                                         72 hours after we receive your request (or
Be sure to ask for a “fast” or “expedited” review.
                                                         your physician's supporting statement if your
If your doctor asks for a fast decision for you, or


                                                                                                      129
   request involves an exception), your request         of complaint called a “fast grievance.” For
   will automatically go to Appeal Level 2              more information about fast grievances, see
• For a fast initial determination about a              the “Grievances” section. If you have not
  Part D drug that you have not yet received            received an answer from us within 14 days of
   If we give you a fast review, we will give you       your request (or by the end of any extended
   our decision within 24 hours after you or your       time period), you have the right to appeal
   doctor ask for a fast review. We will give you    • For a fast decision about Part C Services
   the decision sooner if your health condition        you have not yet received
   requires us to. If your request involves a           If you receive a “fast” decision, we will give
   request for an exception, we will give you our       you our decision about your requested
   decision no later than 24 hours after we have        Services within 72 hours after we receive the
   received your physician's “supporting                request. However, we can take up to 14 more
   statement,” which explains why the drug you          days if we find that some information is
   are asking for is Medically Necessary. If we         missing that may benefit you, or if you need
   decide you are eligible for a fast review and        more time to prepare for this review. If we
   you have not received an answer from us              take additional days, we will notify you in
   within 24 hours after receiving your request         writing. If you believe that we should not take
   (or your physician's supporting statement if         any extra days, you can file a fast grievance.
   your request involves an exception), your            We will call you as soon as we make the
   request will automatically go to Appeal Level        decision. If we do not tell you about our
   2                                                    decision within 72 hours (or by the end of any
• For a decision about payment for Part C               extended time period), this is the same as
  Services you have already received                    denying the request and you have the right to
   If we do not need more information to make a         appeal. If we deny your request for a fast
   decision, we have up to 30 days to make a            decision, you may file a “fast grievance.” For
   decision after we receive your request.              more information about fast grievances, see
   However, if we need more information in              the “Grievances” section
   order to make a decision, we have up to 60
   days from the date of the receipt of your         What happens if we decide completely in your
   request to make a decision. You will be told      favor?
   in writing when we make a decision. If you        • For a standard decision about a Part D
   have not received an answer from us within          drug (including a request to pay for a
   60 days of your request, this is the same as        Part D drug that you have already received)
   denying your request and you have the right          We must cover the Part D drug you requested
   to appeal                                            as quickly as your health requires, but no later
• For a standard decision about Part C                  than 72 hours after we receive the request.
  Services you have not yet received                    If your request involves a request for an
   We have 14 days to make a decision after we          exception, we must cover the Part D drug you
   receive your request. However, we can take           requested no later than 72 hours after we
   up to 14 more days if you ask for additional         receive your physician's “supporting
   time, or if we need more information (such as        statement”.
   medical records) that may benefit you. If we         If you are asking us to pay for a Part D drug
   take additional days, we will notify you in          that you have already received, we must send
   writing. If you believe that we should not take      payment no later than 30 calendar days after
   additional days, you can make a specific type        we receive your request (or supporting

130
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


    statement if your request involves an            Appeal Level 1: Appeal to our Plan
    exception)
                                                     You may ask us to review our initial
• For a fast decision about a Part D drug that       determination, even if only part of our decision is
  you have not yet received                          not what you requested. An appeal to our plan
   We must cover the Part D drug you requested       about a Part D drug is also called a plan
   no later than 24 hours after we receive your      “redetermination.” An appeal to our Plan about
   request. If your request involves a request for   Part C Services is also called a plan
   an exception, we must cover the Part D drug       “reconsideration.” When we receive your request
   you requested no later than 24 hours after we     to review the initial determination, we give the
   receive your physician's “supporting              request to people in our organization who were
   statement”                                        not involved in making the initial determination.
• For a decision about payment for Part C            This helps ensure that we will give your request a
  Services you have already received                 fresh look.




                                                                                                           Part Two − Senior Advantage
   Generally, we must send payment no later
   than 30 days after we receive your request,       Who may file your appeal of the initial
   although some decisions may take up to 60         determination?
   days when we need more information to             If you are appealing an initial decision about a
   make a decision                                   Part D drug, you or your representative may file a
• For a standard decision about Part C               standard appeal request; or you, your
  Services you have not yet received                 representative, or your doctor may file a fast
   We must authorize or provide your requested       appeal request. Please see “Who may ask for an
   care within 14 days of receiving your request.    initial determination?” for information about
   If we extended the time needed to make our        appointing a representative.
   decision, we will authorize or provide your
   medical care before the extended time period      If you are appealing an initial decision about
   expires                                           Part C Services, the rules about who may file an
                                                     appeal are the same as the rules about who may
• For a fast decision about Part C Services
                                                     ask for an organization determination. Follow the
  you have not yet received
                                                     instructions under “Who may ask for an initial
   We must authorize or provide your requested
                                                     determination?” However, providers who do not
   care within 72 hours of receiving your
                                                     have a contract with our Plan may also appeal a
   request. If we extended the time needed to
                                                     payment decision as long as the provider signs a
   make our decision, we will authorize or
                                                     “waiver of payment” statement saying it will not
   provide your medical care before the
                                                     ask you to pay for the Part C Service under
   extended time period expires
                                                     review, regardless of the outcome of the appeal.
What happens if we decide against you?
                                                     How soon must you file your appeal?
If we decide against you, we will send you a
                                                     You must file the appeal request within 60
written decision explaining why we denied your
                                                     calendar days from the date included on the
request. If an initial determination does not give
                                                     notice of our initial determination. We may give
you all that you requested, you have the right to
                                                     you more time if you have a good reason for
appeal our decision (see Appeal Level 1).
                                                     missing the deadline.




                                                                                                    131
How to file your appeal                                Getting information to support your appeal
Asking for a standard appeal: To ask for a             We must gather all the information we need to
standard appeal about a Part C Service or Part D       make a decision about your appeal. If we need
drug a signed, you or your representative must         your assistance in gathering this information, we
send a signed written appeal request to the            will contact you or your representative. You have
address listed in the “Helpful Phone Numbers and       the right to obtain and include additional
Resources” section under “Contact information          information as part of your appeal. For example,
for grievances, organization determinations,           you may already have documents related to your
coverage determinations, and appeals” (for             request, or you may want to get your doctor's
appeals about Part D drugs or Part C Services).        records or opinion to help support your request.
                                                       You may need to give the doctor a written request
Asking for a fast appeal: If you are appealing a       to get information.
decision we made about giving you a Part C
Service or Part D drug that you have not received      You may give us your additional information to
yet, you and/or your doctor will need to decide if     support your appeal by calling, faxing, or writing
you need a fast appeal. The rules about asking for     us at the numbers or address listed in the “Helpful
a fast appeal are the same as the rules about          Phone Numbers and Resources” section under
asking for a fast initial determination. You, your     “Contact information for grievances, organization
doctor, or your representative may ask us for a        determinations, coverage determinations, and
fast appeal by calling, faxing, or writing us at the   appeals” (for appeals about Part D drugs or
numbers or address listed in the “Helpful Phone        Part C Services).
Numbers and Resources” section under “Contact
information for grievances, organization               You may also deliver additional information in
determinations, coverage determinations, and           person to address listed in the “Helpful Phone
appeals” (for appeals about Part D drugs or            Numbers and Resources” section under “Contact
Part C Services).                                      information for grievances, organization
                                                       determinations, coverage determinations, and
Be sure to ask for a “fast” or “expedited” review.     appeals” (for appeals about Part D drugs or
Remember, if your doctor provides a written or         Part C Services).
oral supporting statement explaining that you
need the fast appeal, we will automatically give       You also have the right to ask us for a copy of
you a fast appeal. If you ask for a fast decision      information regarding your appeal. You may call
without support from a doctor, we will decide if       or write us at the phone number or address listed
your health requires a fast decision. If we decide     in the “Helpful Phone Numbers and Resources”
that your medical condition does not meet the          section under “Contact information for
requirements for a fast decision, we will send you     grievances, organization determinations,
a letter informing you that if you get a doctor's      coverage determinations, and appeals” (for
support for a fast review, we will automatically       appeals about Part D drugs or Part C Services).
give you a fast decision. The letter will also tell    We are allowed to charge a fee for copying and
you how to file a “fast grievance.” You have the       sending this information to you.
right to file a fast grievance if you disagree with
our decision to deny your request for a fast           How soon must we decide on your appeal?
review (for more information about fast
                                                       • For a standard decision about a Part D
grievances, see the “Grievances” section). If we
                                                         drug (including a request to pay for a
deny your request for a fast appeal, we will give
                                                         Part D drug you have already received)
you a standard appeal.
132
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


   We will give you our decision within seven          request will automatically go to Appeal Level
   calendar days of receiving the appeal request.      2
   We will give you the decision sooner if you
   have not received the drug yet and your          What happens if we decide completely in your
   health condition requires us to. If we do not    favor?
   give you our decision within seven calendar
   days, your request will automatically go to      • For a standard decision about a Part D
   Appeal Level 2                                     drug (including a request to pay for a
                                                      Part D drug that you have already received)
• For a fast decision about a Part D drug that         We must cover the Part D drug you requested
  you have not yet received                            as quickly as your health requires, but no later
   We will give you our decision within 72             than seven calendar days after we receive the
   hours after we receive the appeal request. We       request. If you are asking us to pay for a
   will give you the decision sooner if your           Part D drug that you have already received,




                                                                                                          Part Two − Senior Advantage
   health condition requires us to. If we do not       we must send payment to you no later than 30
   give you our decision within 72 hours, your         calendar days after we receive the request
   request will automatically go to Appeal Level
   2                                                • For a fast decision about a Part D drug that
                                                      you have not yet received
• For a decision about payment for Part C              We must cover the Part D drug you requested
  Services you have already received                   as quickly as your health requires, but no later
   After we receive your appeal request, we            than 72 hours after we receive your appeal
   have 60 days to decide. If we do not decide         request
   within 60 days, your appeal automatically
   goes to Appeal Level 2                           • For a decision about payment for Part C
                                                      Services you have already received
• For a standard decision about Part C                 We must pay within 60 days of receiving
  Services you have not yet received                   your appeal request
   After we receive your appeal, we have 30
   days to decide, but we will decide sooner if     • For a standard decision about Part C
   your health condition requires. However, if        Services you have not yet received
   you ask for more time, or if we find that           We must authorize or provide your requested
   helpful information is missing, we can take         care within 30 days of receiving your appeal
   up to 14 more days to make our decision. If         request. If we extended the time needed to
   we do not tell you our decision within 30           decide your appeal, we will authorize or
   days (or by the end of the extended time            provide your requested care before the
   period), your request will automatically go to      extended time period expires
   Appeal Level 2                                   • For a fast decision about Part C Services
• For a fast decision about Part C Services           you have not yet received
  you have not yet received                            We must authorize or provide your requested
   After we receive your appeal, we have 72            care within 72 hours of receiving your appeal
   hours to decide, but we will decide sooner if       request. If we extended the time needed to
   your health condition requires. However, if         decide your appeal, we will authorize or
   you ask for more time, or if we find that           provide your requested care before the
   helpful information is missing, we can take         extended time period expires
   up to 14 more days to make our decision. If
   we do not decide within 72 hours (or by the
   end of the extended time period), your

                                                                                                   133
What happens if we decide against you?                 How soon must the IRE decide?
• For Part D drugs, if we deny any part of your        The IRE has the same amount of time to make its
  first appeal, we will send you a written             decision as our Plan had at Appeal Level 1.
  decision explaining why we denied your
  request. If the first appeal does not give you all   If the IRE decides completely in your favor
  that you requested, you may ask for a review         The IRE will tell you in writing about its decision
  by a government-contracted independent               and the reasons for it.
  review organization (see Appeal
  Level 2)                                             • For a decision to pay for a Part D drug you
• For Part C Services, if our decision is not fully      have already received
  in your favor, we will automatically forward            We must send payment within 30 calendar
  your appeal to a government-contracted                  days from the date we receive notice
  independent review organization (see Appeal             reversing our decision
  Level 2) and so notify you in writing                • For a standard decision about a Part D
                                                         drug you have not yet received
Appeal Level 2: Independent Review                        We must cover the Part D drug you asked for
Entity (IRE)                                              within 72 hours after we receive notice
At the second level of appeal, your appeal is             reversing our decision
reviewed by an outside, Independent Review             • For a fast decision about a Part D drug you
Entity (IRE) that has a contract with the Centers        have not yet received
for Medicare & Medicaid Services (CMS), the               We must authorize or provide the Part D drug
government agency that runs the Medicare                  you asked for within 24 hours after we
program. The IRE has no connection to us. You             receive notice reversing our decision
have the right to ask us for a copy of your case       • For a decision about payment for Part C
file that we send to this entity. We are allowed to      Services you have already received
charge you a fee for copying and sending this
                                                          We must pay within 30 days after we receive
information to you.
                                                          notice reversing our decision

How to file your appeal                                • For a standard decision about Part C
                                                         Services you have not yet received
If you asked for Part D drugs or payment for
                                                          We must authorize your requested Part C
Part D drugs and we did not rule completely in
                                                          Service within 72 hours, or provide it to you
your favor at Appeal Level 1, you may file an
                                                          within 14 days after we receive notice
appeal with the IRE. If you choose to appeal, you
                                                          reversing our decision
must send the appeal request to the IRE. The
decision you receive from our Plan (Appeal Level       • For a fast decision about Part C Services
1) will tell you how to file this appeal, including       We must authorize or provide your requested
who can file the appeal and how soon it must be           Part C Services within 72 hours after we
filed.                                                    receive notice reversing our decision

If you asked for Part C Services, or payment for       What happens if the IRE decides against you?
Part C Services, and we did not rule completely        If the organization that reviews your case in this
in your favor at Appeal Level 1, your appeal is        Appeal Level 2 does not rule completely in your
automatically sent to the IRE.                         favor, you may be able to ask for a review by an
                                                       Administrative Law Judge (see Appeal Level 3).

134
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


Appeal Level 3: Administrative Law                     What happens if the Judge decides against you?
Judge (ALJ)                                            If an ALJ does not rule in your favor, your case
If the IRE does not rule completely in your favor,     may be reviewed by the Medicare Appeals
you or your representative may ask for a review        Council (see Appeal Level 4).
by an Administrative Law Judge (ALJ) if the
dollar value of the Part C Service or Part D drug      Appeal Level 4: Medicare Appeals
you asked for meets the minimum requirement            Council (MAC)
provided in the IRE's decision. During the ALJ         If the ALJ does not rule completely in your favor,
review, you may present evidence, review the           you or your representative may ask for a review
record (by either receiving a copy of the file or      by the Medicare Appeals Council (MAC).
accessing the file in person when feasible), and
be represented by counsel.                             How to file your appeal
                                                       The request must be filed in writing with the




                                                                                                            Part Two − Senior Advantage
How to file your appeal                                MAC within 60 calendar days of the date you
The request must be filed in writing with an ALJ       were notified of the decision made by the ALJ
within 60 calendar days of the date you were           (Appeal Level 3). The MAC may give you more
notified of the decision made by the IRE (Appeal       time if you have a good reason for missing the
Level 2). The ALJ may give you more time if you        deadline. The decision you receive from the ALJ
have a good reason for missing the deadline. The       will tell you how to file this appeal, including
decision you receive from the IRE will tell you        who can file it.
how to file this appeal, including who can file it.
                                                       How soon will the council make a decision?
The ALJ will not review your appeal if the dollar
                                                       The MAC will first decide whether to review
value of the requested Part C Service or Part D
                                                       your case (it does not review every case it
drug does not meet the minimum requirement
                                                       receives). If the MAC reviews your case, it will
specified in the IRE's decision. If the dollar value
                                                       make a decision as soon as possible. If it decides
is less than the minimum requirement, you may
                                                       not to review your case, you may request a
not appeal any further.
                                                       review by a Federal Court Judge (see Appeal
                                                       Level 5). The MAC will issue a written notice
How soon will the judge make a decision?               explaining any decision it makes. The notice will
The ALJ will hear your case, weigh all of the          tell you how to request a review by a Federal
evidence, and make a decision as soon as               Court Judge.
possible.
                                                       If the council decides in your favor
If the judge decides in your favor                     See the section “Favorable Decisions by the
See the section “Favorable Decisions by the            ALJ, MAC, or a Federal Court Judge” below
ALJ, MAC, or a Federal Court Judge” below              for information about what we must do if our
for information about what we must do if our           decision denying what you asked for is reversed
decision denying what you asked for is reversed        by the MAC.
by an ALJ.
                                                       What happens if the Council decides against
                                                       you?
                                                       You have the right to continue your appeal by
                                                       asking a Federal Court Judge to review your case


                                                                                                     135
if the amount involved meets the minimum             decision denying what you asked for is reversed
requirement specified in the Medicare Appeals        by a Federal Court Judge.
Council's decision (see Appeal Level 5).
                                                     If the judge decides against you
Appeal Level 5: Federal Court                        You may have further appeal rights in the federal
You have the right to continue your appeal by        courts. Please refer to the Judge's decision for
asking a Federal Court Judge to review your case     further information about your appeal rights.
if the amount involved meets the minimum
requirement specified in the Medicare Appeals        Favorable Decisions by the ALJ, MAC, or a
Council's decision, and you received a decision      Federal Court Judge
from the Medicare Appeals Council (Appeal            This section explains what we must do if our
Level 4), and:                                       decision denying what you asked for is reversed
• The decision is not completely favorable to        by the ALJ, MAC, or a Federal Court Judge.
  you, or                                            • For a decision to pay for a Part D drug you
• The decision tells you that the MAC decided          have already received
  not to review your appeal request                     We must send payment within 30 calendar
                                                        days from the date we receive notice
How to file your appeal                                 reversing our decision
In order to request judicial review of your case,    • For a standard decision about a Part D
you must file a civil action in a United States        drug you have not yet received
district court within 60 calendar days after the        We must cover the Part D drug you asked for
date you were notified of the decision made by          within 72 hours after we receive notice
the Medicare Appeals Council (Appeal Level 4).          reversing our decision
The letter you get from the Medicare Appeals         • For a fast decision about a Part D drug you
Council will tell you how to request this review,      have not yet received
including who can file the appeal.
                                                        We must cover the Part D drug you asked for
                                                        within 24 hours after we receive notice
Your appeal request will not be reviewed by a           reversing our decision
federal court if the dollar value of the requested
Part C Service or Part D drug does not meet the      • For a decision about Part C Services
minimum requirement specified in the MAC's              We must pay for, authorize, or provide the
decision.                                               Service you have asked for as quickly as your
                                                        health condition requires, but no later than 60
How soon will the judge make a decision?                days after we receive notice reversing our
                                                        decision
The Federal Court Judge will first decide whether
to review your case. If it reviews your case, a
decision will be made according to the rules
                                                     PART 2. Complaints (Appeals) if You
established by the federal judiciary.                Think You are Being Discharged From
                                                     the Hospital Too Soon
If the judge decides in your favor                   When you are admitted to the hospital, you have
See the section “Favorable Decisions by the          the right to get all the hospital care covered by
ALJ, MAC, or a Federal Court Judge” below            our Plan that is necessary to diagnose and treat
for information about what we must do if our         your illness or injury. The day you leave the
                                                     hospital (your discharge date) is based on when

136
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


your stay in the hospital is no longer Medically     Review of your hospital discharge by the Quality
Necessary. This part explains what to do if you      Improvement Organization
believe that you are being discharged too soon.      You have the right to request a review of your
                                                     discharge. You may ask the Quality Improvement
Information you should receive during your           Organization to review whether you are being
hospital stay                                        discharged too soon.
Within two days of admission as an inpatient or
during preadmission, someone at the hospital         What is the “Quality Improvement
must give you a notice called the “Important         Organization”?
Message from Medicare” (call our Member              “QIO” stands for Quality Improvement
Service Call Center or 800-MEDICARE/                 Organization. The QIO is a group of doctors and
800-633-4227 (TTY users call 877-486-2048) to        other health care experts paid by the federal
get a sample notice or see it online at              government to check on and help improve the




                                                                                                          Part Two − Senior Advantage
www.cms.hhs.gov/BNI). This notice explains:          care given to Medicare patients. They are not part
• Your right to get all Medically Necessary          of our Plan or the hospital. There is one QIO in
  hospital Services paid for by our Plan (except     each state. QIOs have different names, depending
  for any applicable Copayments or deductibles)      on which state they are in. In California, the QIO
• Your right to be involved in any decisions that    is called Health Services Advisory Group, Inc.,
  the hospital, your doctor, or anyone else makes    located at 5201 W. Kennedy Boulevard, Suite
  about your hospital Services and who will pay      900, Tampa, Florida. The doctors and other
  for them                                           health experts in the QIO review certain types of
                                                     complaints made by Medicare patients. These
• Your right to get Services you need after you      include complaints from Medicare patients who
  leave the hospital                                 think their hospital stay is ending too soon.
• Your right to appeal a discharge decision and
  have your hospital Services paid for by us         Getting the QIO to review your hospital
  during the appeal (except for any applicable       discharge
  Copayments or deductibles)                         You must quickly contact the QIO. The
                                                     “Important Message from Medicare” gives the
You (or your representative) will be asked to sign   name and telephone number of the QIO and tells
the “Important Message from Medicare” to show        you what you must do.
that you received and understood this notice.
Signing the notice does not mean that you            • You must ask the QIO for a “fast review” of
agree that the coverage for your Services              your discharge. This “fast review” is also
should end, only that you received and                 called an “immediate review”
understand the notice. If the hospital gives you     • You must request a review from the QIO no
the “Important Message from Medicare” more             later than the day you are scheduled to be
than two days before your discharge day, it must       discharged from the hospital. If you meet this
give you a copy of your signed “Important              deadline, you may stay in the hospital after
Message from Medicare” before you are                  your discharge date without paying for it
scheduled to be discharged.                            while you wait to get the decision from the
                                                       QIO
                                                     • The QIO will look at your medical information
                                                       provided to the QIO by us and the hospital



                                                                                                   137
• During this process you will get a notice,        continue to receive inpatient care. If the QIO
  called the “Detailed Notice of Discharge,”        agrees that your care should continue, we must
  giving the reasons why we believe that your       pay for, or reimburse you for, any care you have
  discharge date is medically appropriate. Call     received since the discharge date on the
  our Member Service Call Center or                 “Important Message from Medicare,” and
  800-MEDICARE/800-633-4227 (TTY users              provide you with inpatient care (except for any
  call 877-486-2048) to get a sample notice or      applicable Copayment or Coinsurance) for as
  see it online at www.cms.hhs.gov/BNI)             long as it is Medically Necessary and you have
• The QIO will decide, within one day after         not exceeded our Plan coverage limitations as
  receiving the medical information it needs,       described in the “Benefits, Copayments and
  whether it is medically appropriate for you to    Coinsurance” Section.
  be discharged on the date that has been set for
  you                                               If the QIO upholds its original decision, you may
                                                    be able to appeal its decision to an Administrative
What happens if the QIO decides in your favor?      Law Judge (ALJ). Please see Appeal Level 3 in
                                                    Part 1 of this “Requests for Services or Payment,
We will continue to cover your hospital stay
                                                    Complaints, and Medicare Appeal Procedures”
(except for any applicable Copayments or
                                                    section for guidance on the ALJ appeal. If the
Coinsurance) for as long as it is Medically
                                                    ALJ upholds the decision, you may also be able
Necessary and you have not exceeded our Plan
                                                    to ask for a review by the Medicare Appeals
coverage limitations as described in the
                                                    Council (MAC) or a federal court. If any of these
“Benefits, Copayments, and Coinsurance”
                                                    decision makers agree that your stay should
Section.
                                                    continue, we must pay for, or reimburse you for,
                                                    any care you have received since the discharge
What happens if the QIO agrees with the
                                                    date, and provide you with inpatient care (except
discharge?                                          for any applicable Copayment or Coinsurance)
You will not be responsible for paying the          for as long as it is Medically Necessary and you
hospital charges until noon of the day after the    have not exceeded our Plan coverage limitations
QIO gives you its decision. However, you could      as described in the “Benefits, Copayments and
be financially liable for any inpatient hospital    Coinsurance” Section.
Services provided after noon of the day after the
QIO gives you its decision. You may leave the       What if you do not ask the QIO for a review by
hospital on or before that time and avoid any       the deadline?
possible financial liability.
                                                    If you do not ask the QIO for a fast review of
                                                    your discharge by the deadline, you may ask us
If you remain in the hospital, you may still ask
                                                    for a “fast appeal” of your discharge, which is
the QIO to review its first decision if you make
                                                    discussed in Part 1 of this section. If you ask us
the request within 60 days of receiving the QIO's
                                                    for a fast appeal of your discharge and you stay in
first denial of your request. However, you could
                                                    the hospital past your discharge date, you may
be financially liable for any inpatient hospital
                                                    have to pay for the hospital care you receive past
Services provided after noon of the day after the
                                                    your discharge date. Whether you have to pay or
QIO gave you its first decision.
                                                    not depends on the decision we make.
What happens if you appeal the QIO decision?        • If we decide, based on the fast appeal, that you
                                                      need to stay in the hospital, we will continue to
The QIO has 14 days to decide whether to uphold
                                                      cover your hospital care (except for any
its original decision or agree that you should

138
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  applicable Copayment or Coinsurance) for as        Information you will receive during your SNF,
  long as it is Medically Necessary and you have     HHA, or CORF stay
  not exceeded our Plan coverage limitations as      Your provider will give you written notice called
  described in the “Benefits, Copayments and         the “Notice of Medicare Non-Coverage” at least
  Coinsurance” Section                               two days before coverage for your Services ends
• If we decide that you should not have stayed in    call our Member Service Call Center or
  the hospital beyond your discharge date, we        800-MEDICARE/800-633-4227 (TTY users call
  will not cover any hospital care you received      877-486-2048) to get a sample notice or see it
  after the discharge date                           online at www.cms.hhs.gov/BNI. You (or your
                                                     representative) will be asked to sign and date this
If we uphold our original decision, we will          notice to show that you received it. Signing the
forward our decision and case file to the            notice does not mean that you agree that
Independent Review Entity (IRE) within 24            coverage for your Services should end, only




                                                                                                           Part Two − Senior Advantage
hours. Please see Appeal Level 2 in Part 1 of this   that you received and understood the notice.
“Requests for Services or Payment, Complaints,
and Medicare Appeal Procedures” section for          Getting QIO review of our decision to end
guidance on the IRE appeal. If the IRE upholds       coverage
our decision, you may also be able to ask for a      You have the right to appeal our decision to end
review by an ALJ, MAC, or a federal court. If        coverage for your Services. As explained in the
any of these decision makers agree that your stay    notice you get from your provider, you may ask
should continue, we must pay for, or reimburse       the Quality Improvement Organization (the
you for, any care you have received since the        “QIO”) to do an independent review of whether it
discharge date on the notice you got from your       is medically appropriate to end coverage for your
provider, and provide you with any Services you      Services.
asked for (except for any applicable Copayment
or Coinsurance) for as long as it is Medically       How soon do you have to ask for QIO review?
Necessary and you have not exceeded our Plan
                                                     You must quickly contact the QIO. The written
coverage limitations as described in the
                                                     notice you got from your provider gives the name
“Benefits, Copayments and Coinsurance”
                                                     and telephone number of your QIO and tells you
Section.
                                                     what you must do.
PART 3. Complaints (Appeals) If You                  • If you get the notice two days before your
Think Coverage for Your SNF, HHA, or                   coverage ends, you must contact the QIO no
CORF Services is Ending Too Soon                       later than noon of the day after you get the
                                                       notice
When you are a patient in a Skilled Nursing
                                                     • If you get the notice more than two days
Facility (SNF), Home Health Agency (HHA), or
                                                       before your coverage ends, you must make
Comprehensive Outpatient Rehabilitation Facility
                                                       your request no later than noon of the day
(CORF), you have the right to get all the SNF,
                                                       before the date that your Medicare coverage
HHA, or CORF care covered by our Plan that is
                                                       ends
necessary to diagnose and treat your illness or
injury. The day we end coverage for your SNF,
                                                     What will happen during the QIO's review?
HHA, or CORF Services is based on when these
Services are no longer Medically Necessary. This     The QIO will ask why you believe coverage for
part explains what to do if you believe that         the Services should continue. You don't have to
coverage for your Services is ending too soon.       prepare anything in writing, but you may do so if


                                                                                                    139
you wish. The QIO will also look at your medical     applicable Copayment or Coinsurance) for as
information, talk to your doctor, and review         long as it is Medically Necessary and you have
information that we have given to the QIO.           not exceeded our Plan coverage limitations as
During this process, you will get a notice called    described in the “Benefits, Copayments and
the “Detailed Explanation of Non-Coverage”           Coinsurance” Section.
giving the reasons why we believe coverage for
your Services should end. Call our Member            If the QIO upholds its original decision, you may
Service Call Center or 800-MEDICARE/                 be able to appeal its decision to an Administrative
800-633-4227 (TTY users call 877-486-2048) to        Law Judge (ALJ). Please see Appeal Level 3 in
get a sample notice or see it online at              Part 1 of this “Requests for Services or Payment,
www.cms.hhs.gov/BNI.                                 Complaints, and Medicare Appeal Procedures”
The QIO will make a decision within one full day     section for guidance on the ALJ appeal. If the
after it receives all the information it needs.      ALJ upholds our decision, you may also be able
                                                     to ask for a review by the Medicare Appeals
What happens if the QIO decides in your favor?       Council (MAC) or a federal court. If either the
We will continue to cover your SNF, HHA, or          MAC or federal court agrees that your stay
CORF Services (except for any applicable             should continue, we must pay for, or reimburse
Copayment or Coinsurance) for as long as it is       you for, any care you have received since the
Medically Necessary and you have not exceeded        termination date on the notice you got from your
any coverage limitations described in the            provider, and provide you with any Services you
“Benefits, Copayments and Coinsurance”               asked for (except for any applicable Copayment
Section.                                             or Coinsurance) for as long as it is Medically
                                                     Necessary and you have not exceeded our Plan
What happens if the QIO agrees that your             coverage limitations as described in the
coverage should end?                                 “Benefits, Copayments and Coinsurance” section.
You will not be responsible for paying for any
                                                     What if you do not ask the QIO for a review by
SNF, HHA, or CORF Services provided before
the termination date on the notice you get from      the deadline?
your provider. You may stop getting Services on      If you do not ask the QIO for a review by the
or before the date given on the notice and avoid     deadline, you may ask us for a fast appeal, which
any possible financial liability. If you continue    is discussed in Part 1 of this “Requests for
receiving Services, you may still ask the QIO to     Services or Payment, Complaints, and Medicare
review its first decision if you make the request    Appeal Procedures” section.
within 60 days of receiving the QIO's first denial   If you ask us for a fast appeal of your coverage
of your request.                                     ending and you continue getting Services from
                                                     the SNF, HHA, or CORF, you may have to pay
What happens if you appeal the QIO decision?         for the care you get after your termination date.
                                                     Whether you have to pay or not depends on the
The QIO has 14 days to decide whether to uphold
                                                     decision we make.
its original decision or agree that you should
continue to receive Services. If the QIO agrees      • If we decide, based on the fast appeal, that
that your Services should continue, we must pay        coverage for your Services should continue,
for, or reimburse you for, any care you have           we will continue to cover your SNF, HHA, or
received since the termination date on the notice      CORF Services (except for any applicable
you got from your provider, and provide you with       Copayment or Coinsurance) for as long as it is
any Services you asked for (except for any             Medically Necessary and you have not

140
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


  exceeded our Plan coverage limitations as          CalPERS administrative review process
  described in the “Benefits, Copayments and         CalPERS staff may conduct an administrative
  Coinsurance” Section                               review of your dispute if we deny your grievance
• If we decide that you should not have              or Medicare appeal. However, your written
  continued getting Services, we will not cover      request must be submitted to CalPERS within 30
  any Services you received after the termination    days of the date of our denial letter.
  date
                                                     If the dispute remains unresolved during the
If we uphold our original decision, we will          administrative review process, the matter may
forward our decision and case file to the            proceed to an Administrative Hearing. During the
Independent Review Entity (IRE) within 24            hearing, evidence and testimony will be presented
hours. Please see Appeal Level 2 in Part 1 of this   to an Administrative Law Judge. As an
“Requests for Services or Payment, Complaints,       alternative to this hearing, you may have recourse




                                                                                                          Part Two − Senior Advantage
and Medicare Appeal Procedures” section for          through binding arbitration (or Small Claims
guidance on the IRE appeal. If the IRE upholds       Court if applicable). However, you must choose
our decision, you may also be able to ask for a      between the Administrative Hearing and binding
review by an ALJ, MAC, or a federal court. If        arbitration (or Small Claims Court if applicable).
any of these decision makers agree that your stay    You may not take the same issue through both
should continue, we must pay for, or reimburse       procedures. You may withdraw your request from
you for, any care you have received since the        CalPERS at any time, and proceed to binding
discharge date on the notice you got from your       arbitration (or Small Claims Court if applicable).
provider, and provide you with any Services you
asked for (except for any applicable Copayment       To request an administrative review, please
or Coinsurance) for as long as it is Medically       contact CalPERS Office of Employer and
Necessary and you have not exceeded our Plan         Member Health Services at P.O. Box 942714,
coverage limitations as described in the             Sacramento, CA 94229-2714, fax number
“Benefits, Copayments, and Coinsurance”              916-795-1277, or telephone the CalPERS
Section.                                             Customer Service and Education Division at
                                                     888-CalPERS (888-225-7377).




                                                                                                   141
TERMINATION OF MEMBERSHIP

Your Group is required to inform the Subscriber        Post-Stabilization Care, and Out-of-Area Urgent
of the date your membership terminates. The            Care and the “Benefits, Copayments, and
guidelines that determine the termination of           Coinsurance” section about out-of-area dialysis
coverage from the CalPERS Health Program are           care.
governed in accord with the Public Employees’
Medical & Hospital Care Act (PEMHCA). For an           Note: If you enroll in another Medicare health
explanation of specific eligibility criteria and       plan or a Prescription Drug Plan, your Senior
termination requirements, please consult your          Advantage membership will terminate as
Health Benefits Officer (or, if you are retired, the   described under “Disenrolling from Senior
CalPERS Office of Employer and Member                  Advantage” in this “Termination of Membership”
Health Services). Your CalPERS Health                  section.
Program Guide also includes eligibility and
termination information and can be ordered             Termination Due to Loss of Eligibility
through the CalPERS Web site or by calling
                                                       If you meet the eligibility requirements described
CalPERS.
                                                       under “Eligibility” in the “Premiums, Eligibility,
                                                       and Enrollment” section on the first day of a
Your membership termination date is the first day
                                                       month, but later in that month you no longer meet
you are not covered (for example, if your
                                                       those eligibility requirements, your membership
termination date is January 1, 2010, your last
                                                       will end at 11:59 p.m. on the last day of that
minute of coverage was at 11:59 p.m. on
                                                       month. For example, if you become ineligible on
December 31, 2009). When a Subscriber's
                                                       December 5, 2009, your termination date is
membership ends, the memberships of any
                                                       January 1, 2010, and your last minute of coverage
Dependents end at the same time. You will be
                                                       is at 11:59 p.m. on December 31, 2009.
billed as a non-Member for any Services you
receive after your membership terminates.
                                                       Also, we will terminate your Senior Advantage
                                                       membership on the last day of the month if you:
Health Plan and Plan Providers have no further
liability or responsibility under this DF/EOC          • Are temporarily absent from your Home
after your membership terminates, except:                Region’s Service Area for more than six
                                                         months in a row
• As provided under “Payments after
  Termination” in this “Termination of                 • Permanently move from your Home Region’s
  Membership” section                                    Service Area
• If you are receiving covered Services as an          • No longer are entitled to Medicare Part B.
  acute care hospital inpatient on the termination     • Enroll in another Medicare-health plan (for
  date, we will continue to cover those hospital         example, a Medicare Advantage Plan or a
  Services (but not physician Services or any            Medicare Prescription Drug Plan). CMS will
  other Services) until you are discharged               automatically terminate your Senior
                                                         Advantage membership when your enrollment
Until your membership terminates, you remain a           in the other plan becomes effective
Senior Advantage Member and must continue to
receive your medical care from us, except as           Note: If you lose eligibility for Senior Advantage
described in the “Emergency, Urgent, and               due to these circumstances, you may be eligible
Routine Care” section about Emergency Care,
142
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


to transfer your membership to another Kaiser                    Kaiser Foundation Health Plan, Inc
Permanente plan offered by your Group. Please                    California Service Center
contact your Group’s Health Benefits Officer (or,                P.O. Box 232400
if you are retired, the CalPERS Office of                        San Diego, CA 92193-2400
Employer and Member Health Services) for
information.                                          Other Medicare health plans. If you want to
                                                      enroll in another Medicare health plan or a
Termination of Agreement                              Medicare Prescription Drug Plan, you should first
                                                      confirm with the other plan and your Group that
If your Group’s Agreement with us terminates for
                                                      you are able to enroll in their plan. Your new plan
any reason, your membership ends on the same
                                                      will tell you the date when your membership in
date. Your Group is required to notify
                                                      that plan begins and your Senior Advantage
Subscribers in writing if its Agreement with us
                                                      membership will end on that same day (your
terminates.
                                                      disenrollment date).




                                                                                                            Part Two − Senior Advantage
Disenrolling from Senior Advantage
                                                      CMS will let us know if you enroll in another
Please check with the CalPERS Office of               Medicare health plan, so you will not need to
Employer and Member Health Services at the            send us a disenrollment request.
CalPERS Customer Service and Education
Division at 888-CalPERS (888-225-7377) before         Original Medicare. If you request disenrollment
you disenroll from Senior Advantage.                  from Senior Advantage and you do not enroll in
Disenrolling from Senior Advantage so you can         another Medicare health plan, you will
return to Original Medicare or at any time other      automatically be enrolled in Original Medicare
than CalPERS open enrollment period may result        when your Senior Advantage membership
in loss of CalPERS-sponsored health coverage.         terminates (your disenrollment date). On your
                                                      disenrollment date, you can start using your red,
If you request disenrollment during your Group’s      white, and blue Medicare card to get services
open enrollment, your disenrollment effective         under Original Medicare. You will not get
date is determined by the date your written           anything in writing that tells you that you have
request is received by us and the date your Group     Original Medicare after you disenroll. If you
coverage ends. The effective date will not be         choose Original Medicare and you want to
earlier than the first day of the following month     continue to get Medicare Part D prescription drug
after we receive your written request, and no later   coverage, you will need to enroll in a Prescription
than three months after we receive your request.      Drug Plan.

If you request disenrollment at a time other than     Termination of Contract with CMS
your Group’s open enrollment, your
                                                      If our contract with CMS to offer Senior
disenrollment effective date will be the first day
                                                      Advantage terminates, your membership will
of the month following our receipt of your
                                                      terminate on the same date. We will send you
disenrollment request.
                                                      advance written notice and advise you of your
                                                      health care options. Also, you may be eligible to
You may request disenrollment by calling toll
                                                      transfer your membership to another Kaiser
free 800-MEDICARE/800-633-4227 (TTY users
                                                      Permanente plan offered by your Group. Please
call 877-486-2048) or sending written notice to
                                                      contact the CalPERS Office of Employer and
the following address:
                                                      Member Health Services for information.


                                                                                                      143
Termination for Cause                                 Termination of a Product or all Products
If you commit one of the following acts, we will      We may terminate a particular product or all
ask CalPERS to approve termination of your            products offered in a small or large group market
membership in accord with Section 22841 of the        as permitted or required by law. If we discontinue
Government Code. If CalPERS approves                  offering a particular product in a market, we will
termination of your membership, CalPERS will          terminate just the particular product upon 90 days
send written notice to the Subscriber:                prior written notice to you. If we discontinue
• You behave in a way that is disruptive to the       offering all products to groups in a small or large
  extent that your continued enrollment               group market, as applicable, we may terminate
  seriously impairs our ability to arrange or         your Group’s Agreement upon 180 days prior
  provide medical care for you or for our other       written notice to you.
  members. We cannot make you leave our Plan
  for this reason unless we get permission first      Payments after Termination
  from Medicare                                       If we terminate your membership for cause, we
• You let someone else use your Plan                  will:
  membership card to get medical care. If you         • Refund any amounts we owe your Group for
  are disenrolled for this reason, CMS may refer        Premiums paid after the termination date
  your case to the Inspector General for
  additional investigation                            • Pay you any amounts we have determined that
                                                        we owe you for claims during your
• You commit theft from Health Plan, from a             membership in accord with the “Emergency,
  Plan Provider, or at a Plan Facility                  Post-Stabilization, and Urgent Care from Non–
• You intentionally misrepresent membership             Plan Providers” and” “Requests for Services or
  status, or commit fraud in connection with            Payment, Complaints, and Medicare Appeal
  your obtaining membership                             Procedures” sections. We will deduct any
                                                        amounts you owe Health Plan or Plan
• You knowingly falsify or withhold
                                                        Providers from any payment we make to you
  information about other parties that provide
  reimbursement for your prescription drug
  coverage                                            Review of Membership Termination
                                                      If you believe that we terminated your
If we terminate your membership for cause, you        membership because of your ill health or your
will not be allowed to enroll in Health Plan in the   need for care, you may file a grievance as
future until you have completed a Member              described in the “Grievances” section.
Orientation and have signed a statement
promising future compliance. We may also report
fraud and other illegal acts to the authorities for
prosecution.




144
      Member Service Call Center: 800-443-0815 (TTY 800-777-1370) every day 8 a.m.–8 p.m.


CONTINUATION OF MEMBERSHIP

If your membership under this DF/EOC ends,         coverage for your disabling condition will
you may be eligible to maintain Health Plan        continue until any one of the following events
membership without a break in coverage under       occurs:
this DF/EOC (group coverage) or you may be         • 12 months have elapsed
eligible to convert to an individual (nongroup)
plan.                                              • You are no longer disabled
                                                   • Your Group’s Agreement with us is replaced
Continuation of Group Coverage                       by another group health plan without
                                                     limitation as to the disabling condition
COBRA
You may be able to continue your coverage under    Your coverage will be subject to the terms of this




                                                                                                           Part Two − Senior Advantage
this DF/EOC for a limited time after you would     DF/EOC including Copayments and
otherwise lose eligibility, if required by the     Coinsurance.
federal COBRA law. COBRA applies to most
employees (and most of their covered family        For Subscribers and adult Dependents, “totally
Dependents) of most employers with 20 or more      disabled” means that, in the judgment of a
employees.                                         Medical Group physician, an illness or injury is
                                                   expected to result in death or has lasted or is
You must submit a COBRA election form to your      expected to last for a continuous period of at least
Group within the COBRA election period. Please     12 months, and makes the person unable to
ask your Health Benefits Officer (or, if you are   engage in any employment or occupation, even
retired, the CalPERS Office of Employer and        with training, education, and experience.
Member Health Services) for details about
COBRA coverage, such as how to elect coverage,     For Dependent children, “totally disabled” means
how much you must pay your Group for               that, in the judgment of a Medical Group
coverage, when coverage and Premiums may           physician, an illness or injury is expected to result
change, and where to send your Premium             in death or has lasted or is expected to last for a
payments.                                          continuous period of at least 12 months and the
                                                   illness or injury makes the child unable to
As described in “Conversion from Group             substantially engage in any of the normal
Membership to an Individual Plan” in this          activities of children in good health of like age.
“Continuation of Membership” section, you may
be able to convert to an individual (nongroup)     To request continuation of coverage for your
plan if you don’t apply for COBRA coverage, or     disabling condition, you must call our Member
if you enroll in COBRA and your COBRA              Service Call Center within 30 days of the date
coverage ends.                                     your Group’s Agreement with us terminates.

Coverage for a disabling condition                 Conversion from Group Membership to
If you became totally disabled after December      an Individual Plan
31, 1977, while you were a Member under your
Group’s Agreement with us and while the            After your Group notifies us to terminate your
Subscriber was employed by your Group, and         membership, we will send a termination letter to
your Group’s Agreement with us terminates,         the Subscriber’s address of record. The letter will
                                                   include information about options that may be

                                                                                                    145
available to you to remain a Health Plan member      If you are no longer eligible for Senior
through one of our Individual Plans.                 Advantage and Group coverage, you may be
Individual−Conversion Plan coverage begins           eligible to convert to our non-Medicare
when your Group coverage ends. The premiums          individual plan, called “Kaiser Permanente
and coverage under our Individual−Conversion         Individual−Conversion Plan.” You may be
Plans are different from those under this            eligible to enroll in our Individual−Conversion
DF/EOC.                                              Plan if we receive your enrollment application
                                                     within 63 days of the date of our termination
How to convert                                       letter or of your membership termination date
If you no longer qualify as a Member described       (whichever date is later).
under “Eligibility” in the “Premiums, Eligibility,
and Enrollment” section, we will automatically       You may not be eligible to convert if your
convert your Group membership to our Senior          membership ends for the reasons stated under
Advantage Individual Plan Agreement if you still     “Termination for Cause” or “Termination of
meet the eligibility requirements for Senior         Agreement” in the “Termination of Membership”
Advantage and have not disenrolled. The              section.
premiums and coverage under our individual plan
will differ from those under this DF/EOC and         For information about converting your
will include Medicare Part D prescription drug       membership or about other individual plans, call
coverage.                                            our Member Service Call Center.




146
ASH PLANS CHIROPRACTIC SERVICES

ASH Plans Member Services Department:                Medically Necessary Chiropractic Services:
800-678-9133, 5 a.m. to 6 p.m., Monday-              Chiropractic services provided or prescribed by a
Friday, www.ashplans.com.                            chiropractor (including laboratory tests, X-rays,
                                                     and chiropractic appliances) that are appropriate
Please refer to Part Two for information about the   and required for the treatment of your
chiropractic services that Medicare covers, which    Neuromusculoskeletal Disorder in accord with
are separate from the services covered under this    generally accepted professional standards of
“ASH Plans Chiropractic Services” section. This      practice for the chiropractic treatment of
section does not describe services covered by        Neuromusculoskeletal Disorders.
Medicare. Medicare rules determine which
coverage pays first, or is “primary,” and which      Neuromusculoskeletal Disorders: Conditions
coverage pays second, or is “secondary.” Your        with associated signs and symptoms related to the
Medicare coverage is primary unless Medicare is      nervous, muscular, or skeletal systems.
secondary by law.                                    Neuromusculoskeletal Disorders are conditions




                                                                                                          Part Two − Senior Advantage
                                                     typically categorized as structural, degenerative,
Kaiser Foundation Health Plan, Inc., contracts       or inflammatory disorders, or biomechanical
with American Specialty Health Plans of              dysfunction of the joints of the body or related
California, Inc. (ASH Plans) to make the ASH         components of the motor unit (muscles, tendons,
Plans network of Participating Chiropractors         fascia, nerves, ligaments/capsules, discs, and
available to you. When you need chiropractic         synovial structures), and related neurological
care, you have direct access to more than 2,800      manifestations or conditions.
licensed chiropractors in California. You can
obtain covered services from any Participating       Non–Participating Chiropractor: A
Chiropractor without a referral from a Plan          chiropractor other than a Participating
Physician. Copayments and Coinsurance are due        Chiropractor.
when you receive covered services.
                                                     Non–Participating Provider: A provider other
Definitions                                          than a Participating Provider.
In addition to the terms defined in the
                                                     Participating Chiropractor: A chiropractor who
“Definitions” section, the following terms, when
                                                     is licensed to provide chiropractic services in
capitalized in this “ASH Plans Chiropractic
                                                     California and who has a contract with ASH
Services” section, mean:
                                                     Plans to provide Medically Necessary
                                                     Chiropractic Services to you. A list of
Emergency Chiropractic Services: Covered
                                                     Participating Chiropractors is available on the
chiropractic services provided for a sudden and
                                                     ASH Plans Web site at ashplans.com or from the
unexpected onset of an injury or condition
                                                     ASH Plans Member Services Department toll
affecting the neuromusculoskeletal system which
                                                     free at 800-678-9133 (TTY users call 711). The
manifests itself by acute symptoms of sufficient
                                                     list of Participating Chiropractors is subject to
severity (including severe pain) such that you
                                                     change at any time, without notice. If you have
could reasonably expect the absence of
                                                     questions, please call the ASH Plans Member
immediate chiropractic care to result in serious
                                                     Services Department.
jeopardy to your health or body functions or
organs.



                                                                                                   147
Participating Provider: A Participating               Covered Services
Chiropractor, or any licensed provider with which
                                                      We cover the services listed in this “Covered
ASH Plans contracts to provide covered
                                                      Services” section if ASH Plans has authorized the
laboratory tests or X-rays.
                                                      services as part of your Treatment Plan. Covered
                                                      services are provided at the Copayment or
Treatment Plan: A proposed course of treatment
                                                      Coinsurance described in this “Covered Services”
for your Neuromusculoskeletal Disorder, which
                                                      section. However, you may be liable for the cost
may include laboratory tests, X-rays, chiropractic
                                                      of noncovered services you obtain from
appliances, and a specific number of visits for
                                                      Participating Providers or Non–Participating
chiropractic manipulations, adjustments, and
                                                      Providers.
therapies that are Medically Necessary
Chiropractic Services for you.
                                                      Office visits
Participating Providers                               We cover up to 20 of the following types of
                                                      office visits per calendar year at
Please read the following information so you          a $10 Copayment per visit. Each office visit
will know from whom or what group of                  counts toward the calendar year visit limit even if
providers you may receive covered services.           an adjustment is not provided during the visit:
                                                      • Initial examination: An examination
ASH Plans contracts with Participating                  performed by a Participating Chiropractor to
Chiropractors and other Participating Providers to      determine the nature of your problem (and, if
provide covered chiropractic services, including        appropriate, to prepare a Treatment Plan), and
laboratory tests, X-rays, and chiropractic              to provide Medically Necessary Chiropractic
appliances. You must receive covered services           Services, which may include an adjustment
from a Participating Provider, except for               and adjunctive therapy (such as ultrasound, hot
Emergency Chiropractic Services and services            packs, cold packs, or electrical muscle
that are not available from Participating Providers     stimulation). We cover an initial examination
that have been preauthorized by ASH Plans.              only if you have not already received covered
                                                        services from a Participating Chiropractor in
How to obtain services                                  the same calendar year for your
To obtain covered services, call a Participating        Neuromusculoskeletal Disorder
Chiropractor to schedule an initial examination. If   • Subsequent office visits: Subsequent
additional services are required, your                  Participating Chiropractor office visits for
Participating Chiropractor will prepare a               Medically Necessary Chiropractic Services,
Treatment Plan. The ASH Plans Clinical Services         which may include an adjustment, adjunctive
Manager will authorize the Treatment Plan if the        therapy, and a re-examination to assess the
services are Medically Necessary Chiropractic           need to continue, extend, or change a
Services for you. ASH Plans will disclose to you,       Treatment Plan
upon request, the process that it uses to authorize
a Treatment Plan. If you have questions or            Laboratory tests and X-rays
concerns, please contact ASH Plans or Kaiser          We cover Medically Necessary laboratory tests
Permanente as described under “Member                 and X-rays when prescribed as part of covered
Services” in this “ASH Plans Chiropractic             care described under “Office visits” in this
Services” section.                                    “Covered Services” section at no charge when a
                                                      Participating Chiropractor provides the services



148
or refers you to a Participating Provider for the    Emergency Chiropractic Services
services.                                            We cover Emergency Chiropractic Services
                                                     provided by a Participating Chiropractor or a
Chiropractic appliances                              Non–Participating Chiropractor at
We provide a $50 Allowance per calendar year         a $10 Copayment per visit. We do not cover
toward the ASH Plans fee schedule price for          follow-up or continuing care from a Non–
chiropractic appliances listed in this paragraph     Participating Chiropractor unless ASH Plans has
when the item is prescribed and provided to you      authorized the services. Also, we do not cover
by a Participating Chiropractor as part of covered   services from a Non-Participating Chiropractor
care described under “Office visits” in this         that ASH Plans determines are not Emergency
“Covered Services” section. If the price of the      Chiropractic Services. As soon as possible after
item(s) in the ASH Plans fee schedule exceeds        receiving Emergency Chiropractic Services, you
$50 (the Allowance), you will pay the amount in      must file a claim as described in the “Requests
excess of $50 (and that payment does not apply       for Payment or Services” section.
toward your annual out-of-pocket maximum).
Covered chiropractic appliances are limited to:      Member Services
elbow supports, back supports (thoracic), cervical




                                                                                                          Part Two − Senior Advantage
                                                     If you have a question or concern regarding the
collars, cervical pillows, heel lifts, hot or cold
                                                     services you received from a Participating
packs, lumbar braces and supports, lumbar
                                                     Provider, you may call ASH Plans Member
cushions, orthotics, wrist supports, rib belts,
                                                     Services toll free at 800-678-9133 (TTY users
home traction units (cervical or lumbar), ankle
                                                     call 711) weekdays from 5 a.m. to 6 p.m., or write
braces, knee braces, rib supports, and wrist
                                                     ASH Plans at:
braces.
                                                          American Specialty Health Plans of
                                                          California, Inc.
Second opinions                                           Appeals and Grievance Coordinator
If you request a second opinion, it will be               P.O. Box 509002
provided to you by a Participating Chiropractor           San Diego, CA 92150-9002
who is an appropriately qualified chiropractor (a
chiropractor who is acting within his or her scope   You can file a grievance regarding any issue.
of practice and who possesses a clinical             Your grievance must explain your issue, such as
background related to the illness or condition       the reasons why you believe a decision was in
associated with the request for a second medical     error or why you are dissatisfied about services
opinion). To get a second opinion, make an           you received. You may submit your grievance
appointment with a Participating Chiropractor.       orally or in writing to Kaiser Permanente as
Second opinion office visits are provided at         described in the “Dispute Resolution” section.
a $10 Copayment per visit, and count toward
your annual visit limit unless a Participating       Exclusions and Limitations
Chiropractor refers you to another Participating
Chiropractor for a consultation that does not        The following services are not covered under this
include treatment. If ASH Plans determines that      “ASH Plans Chiropractic Services”:
there isn’t a Participating Chiropractor who is an   • Any services not provided by a Participating
appropriately qualified chiropractor for your          Chiropractor or Participating Provider, except
condition, ASH Plans will authorize a referral to      for Emergency Chiropractic Services and
a Non–Participating Chiropractor for a second          services that are not available from
opinion.                                               Participating Providers that are prior
                                                       authorized by ASH Plans


                                                                                                   149
• Services for conditions other than              • Air conditioners, air purifiers, therapeutic
  Neuromusculoskeletal Disorders                    mattresses, chiropractic appliances, durable
• Hypnotherapy, behavior training, sleep            medical equipment, supplies, devices,
  therapy, and weight programs                      appliances, and any other item except those
                                                    listed as covered under “Chiropractic
• Thermography                                      appliances” under the “Covered Services”
• Experimental or investigational services.         section of this “ASH Plans Chiropractic
  Please refer to the “Dispute Resolution”          Services”
  section for information about Independent       • Drugs and medicines, including non-legend or
  Medical Review related to denied requests for     proprietary drugs and medicines
  Medically Necessary and experimental or
  investigational services                        • Services you receive outside the state of
                                                    California, except for Emergency Chiropractic
• Magnetic resonance imaging (MRI), computed        Services
  tomography (CT), positron emission
  tomography (PET), bone scans, nuclear           • Hospital services, anesthesia, manipulation
  radiology, and any types of diagnostic            under anesthesia, and related services
  radiology other than X-rays covered under the   • Adjunctive therapy not associated with spinal,
  “Covered Services” section of this “ASH Plans     muscle, or joint manipulations
  Chiropractic Services”                          • Vitamins, minerals, nutritional supplements,
• Ambulance and other transportation                and similar products
• Education programs, nonmedical self-care or     • Services provided by a chiropractor that are
  self-help, any self-help physical exercise        not within the scope of licensure for a
  training, and any related diagnostic testing      chiropractor licensed in California
• Services for pre-employment physicals or
  vocational rehabilitation




150
HELPFUL PHONE NUMBERS AND RESOURCES

Contact Information for our Member Services          TTY
If you have any questions or concerns, please call   800-777-1370. This number requires special
or write to our Member Services. We will be          telephone equipment. Calls to this number are
happy to help you.                                   free.

Call                                                 Fax
800-443-0815, 8 a.m. to 8 p.m., seven days a         If your grievance, organization or coverage
week. Calls to this number are free.                 determination, or appeal qualifies for a fast
                                                     review, fax your request to our Expedited Review
TTY                                                  Unit at:
800-777-1370. This number requires special           • 888-987-2252 for Part C Services
telephone equipment. Calls to this number are        • 866-206-2974 for Part D drugs
free.




                                                                                                           Part Two − Senior Advantage
                                                     Write
Write
                                                     Member Services office located at a Plan facility
Member Services office located at a Plan facility
                                                     listed in Your Guidebook to Kaiser Permanente
listed in Your Guidebook to Kaiser Permanente
                                                     Services, unless you are requesting an appeal, fast
Services.
                                                     grievance, fast organization or coverage
                                                     determination, or payment for emergency or
Web Site                                             urgent care or Part D drugs you have received
kp.org                                               out-of-network. In these cases, you would write
                                                     to one of the following locations:
Contact information for grievances, organization
                                                     • For a standard appeal, write to the address
determinations, coverage determinations, and           shown on the denial notice we send you (a
appeals                                                standard appeal is one that does not involve a
Call                                                   request for a fast review).
800-443-0815, 8 a.m. to 8 p.m., seven days a         • If your grievance, organization or coverage
week. Calls to this number are free.                   determination, or appeal qualifies for a fast
                                                       review, write to:
If your grievance, organization or coverage             Kaiser Foundation Health Plan, Inc.
determination, or appeal qualifies for a fast           Expedited Review Unit
review, call the Expedited Review Unit,                 P.O. Box 23170
8:30 a.m. to 5 p.m., seven days a week, at:             Oakland, CA 94623-0170
• 888-987-7247 for Part C Services                   • For an initial determination about payment
• 866-206-2973 for Part D drugs                        (including a Part D reimbursement request) for
                                                       emergency or urgent care or Part D drugs you
After hours, you may leave a message and we            received out-of-network, write to:
will return your call the next day.                     Kaiser Foundation Health Plan, Inc.
                                                        Claims Department
                                                        P.O. Box 7004
                                                        Downey, CA 90242-7004


                                                                                                     151
For information about grievances, see the           Quality Improvement Organization
“Grievances” section. For information about         “QIO” stands for Quality Improvement
organization or coverage determinations and         Organization. The QIO is a group of doctors and
appeals, see the “Requests for Services or          health professionals in your state that reviews
Payment, Complaints, and Medicare Appeal            medical care and handles certain types of
Procedures” section.                                complaints from patients with Medicare, and is
                                                    paid by the federal government to check on and
Other Important Contacts                            help improve the care given to Medicare patients.
Below is a list of other important contacts. For    There is a QIO in each state. QIOs have different
the most up-to-date contact information, check      names, depending on which state they are in. The
your Medicare & You Handbook, visit                 doctors and other health experts in the QIO
www.medicare.gov and choose “Find Helpful           review certain types of complaints made by
Phone Numbers and Resources,” or call               Medicare patients. These include complaints
800-MEDICARE/800-633-4227 (TTY users call           about quality of care and appeals filed by
877-486-2048).                                      Medicare patients who think the coverage for
                                                    their hospital, skilled nursing facility, home
The Health Insurance Counseling and Advocacy        health agency, or comprehensive outpatient
                                                    rehabilitation stay is ending too soon. See the
Program (HICAP)
                                                    “Grievances” and “Requests for Services or
The Health Insurance Counseling and Advocacy        Payment, Complaints, and Medicare Appeal
Program (HICAP) is a state program that gets        Procedures” sections for more information about
money from the federal government to give free      complaints, appeals and grievances.
local health insurance counseling to people with
Medicare. HICAP can explain your Medicare
                                                    The QIO for California residents is Health
rights and protections, help you make complaints    Services Advisory Group, Inc., and you may
about care or treatment, and help straighten out
                                                    contact them by writing to Health Services
problems with Medicare bills. HICAP has
                                                    Advisory Group, Inc., Attn: Beneficiary
information about Medicare Advantage Plans,         Protection, 5201 W. Kennedy Boulevard, Suite
Medicare Prescription Drug Plans, Medicare Cost
                                                    900, Tampa, Florida 33609-1822 (fax number
Plans, and Medigap (Medicare supplement
                                                    415-677-2185185), or call toll free
insurance) policies. This includes information      800-841-1602, 24 hours a day, seven days a week
about whether to drop your Medigap policy while
                                                    (TTY users call 800-881-5980).
enrolled in a Medicare Advantage Plan and
special Medigap rights for people who have tried
                                                    Medicare program
a Medicare Advantage Plan for the first time.
                                                    Medicare is the federal health insurance program
You may contact HICAP toll free at                  for people 65 years of age or older, some people
800-434-0222 (TTY users call 711) for a referral    under age 65 with certain disabilities, and people
to your local HICAP office, or visit the Web site   with End-Stage Renal Disease (generally those
www.aging.ca.gov to locate an office in your        with permanent kidney failure who need dialysis
area. You may also find the website for HICAP at    or a kidney transplant). Our organization
www.medicare.gov, under “Search Tools” by           contracts with the federal government.
selecting “Helpful Phone Numbers and                • Call 800-MEDICARE/800-633-4227 (TTY
Websites.”                                            users call 877-486-2048) to ask questions or
                                                      get free information booklets from Medicare,
                                                      24 hours a day, seven days a week

152
• Visit www.medicare.gov for information.          the California Department of Social Services at
  This is the official government website for      800-952-5253, 24 hours a day, seven days a
  Medicare. This website gives you up-to-date      week, (TTY 800-952-8349), or write to the
  information about Medicare and nursing           California Department of Social Services at Post
  homes and other current Medicare issues. It      Office Box 944243, Sacramento, CA 94244.
  includes booklets you can print directly from
  your computer. It has tools to help you          Social Security
  compare Medicare Advantage Plans and             Social Security programs include retirement
  Medicare Prescription Drug Plans in your area.   benefits, disability benefits, family benefits,
  You can also search under “Search Tools” for     survivors' benefits, and benefits for the aged and
  Medicare contacts in your state, select          blind. You may call Social Security toll free at
  “Helpful Phone Numbers and Websites.” If         800-772-1213 (TTY users call 800-325-0778).
  you don't have a computer, your local library    You may also visit www.socialsecurity.gov on
  or senior center may be able to help you visit   the Web.
  this website using its computer
                                                   Railroad Retirement Board




                                                                                                        Part Two − Senior Advantage
Medicaid
                                                   If you get benefits from the Railroad Retirement
Medicaid is a state government program that
                                                   Board, you may call your local Railroad
helps with medical costs for some people with
                                                   Retirement Board office or toll free
limited incomes and resources. Some people with
                                                   800-808-0772 (TTY users call 312-751-4701).
Medicare are also eligible for Medicaid.
                                                   You may also visit www.rrb.gov on the Web.
Medicaid has programs that can help pay for your
Medicare premiums and other costs if you
qualify. To find out more about Medicaid and its
programs, contact your county's Medi-Cal office,




                                                                                                  153
Kaiser Foundation Health Plan, Inc.
Northern and Southern California Regions




PART THREE − DISCLOSURE FORM AND EVIDENCE OF
COVERAGE FOR KAISER PERMANENTE BASIC PLAN AND
KAISER PERMANENTE SENIOR ADVANTAGE



General Information for All Members —The information in this Part Three is applicable to both Basic
Plan DF/EOC (Part One) and Kaiser Permanente Senior Advantage DF/EOC (Part Two).




January 1, 2010, through December 31, 2010




                                                       Member Service Call Center
                                                       800-464-4000 toll free for Basic Plan
                                                       Weekdays 7 a.m.−7 p.m. and
                                                          weekends 7 a.m.−3 p.m. (except holidays)
                                                       800-443-0815 toll free for Senior Advantage
                                                       Every day 8 a.m.–8 p.m.
                                                       800-777-1370 (toll free TTY for the
                                                          hearing/speech impaired)
                                                       kp.org




154
MISCELLANEOUS PROVISIONS

Administration of this Agreement                     Applications and statements
We may adopt reasonable policies, procedures,        You must complete any applications, forms, or
and interpretations to promote orderly and           statements that we request in our normal course
efficient administration of your Group’s             of business or as specified in this DF/EOC.
Agreement, including this DF/EOC.
                                                     Assignment
Advance directives                                   You may not assign this DF/EOC or any of the
The California Health Care Decision Law offers       rights, interests, claims for money due, benefits,
several ways for you to control the kind of health   or obligations hereunder without our prior written
care you will receive if you become very ill or      consent.
unconscious, including the following:
• A Power of Attorney for Health Care lets you       Attorney and advocate fees and expenses
  name someone to make health care decisions         In any dispute between a Member and Health
  for you when you cannot speak for yourself. It     Plan, the Medical Group, or Kaiser Foundation
  also lets you write down your own views on         Hospitals, each party will bear its own fees and




                                                                                                          Part Three
  life support and other treatments                  expenses, including attorneys’ fees, advocates’
• Individual health care instructions let you        fees, and other expenses.
  express your wishes about receiving life
  support and other treatment. You can express       Claims review authority
  these wishes to your doctor and have them          We are responsible for determining whether you
  documented in your medical chart, or you can       are entitled to benefits under this DF/EOC and
  put them in writing and have that included in      we have the discretionary authority to review and
  your medical chart                                 evaluate claims that arise under this DF/EOC.
                                                     We conduct this evaluation independently by
To learn more about advance directives,              interpreting the provisions of this DF/EOC. If
including how to obtain forms, contact your local    this DF/EOC is part of a health benefit plan that
Member Services Department at a Plan Facility.       is subject to the Employee Retirement Income
You can also refer to Your Guidebook for more        Security Act (ERISA), then we are a “named
information about advance directives.                fiduciary” to review claims under this DF/EOC.

Agreement binding on Members                         Governing law
By electing coverage or accepting benefits under     Except as preempted by federal law, this
this DF/EOC, all Members legally capable of          DF/EOC will be governed in accord with
contracting, and the legal representatives of all    California law and any provision that is required
Members incapable of contracting, agree to all       to be in this DF/EOC by state or federal law shall
provisions of this DF/EOC.                           bind Members and Health Plan whether or not set
                                                     forth in this DF/EOC.
Amendment of Agreement
Your Group’s Agreement with us will change           Group and Members not our agents
periodically. If these changes affect this           Neither your Group nor any Member is the agent
DF/EOC, your Group is required to inform you in      or representative of Health Plan.
accord with applicable law and your Group’s
Agreement.


                                                                                                   155
No waiver                                              PHI is health information that includes your
Our failure to enforce any provision of this           name, Social Security number, or other
DF/EOC will not constitute a waiver of that or         information that reveals who you are. You may
any other provision, or impair our right thereafter    generally see and receive copies of your PHI,
to require your strict performance of any              correct or update your PHI, and ask us for an
provision.                                             accounting of certain disclosures of your PHI.

Nondiscrimination                                      We may use or disclose your PHI for treatment,
                                                       payment, and health care operations purposes,
We do not discriminate in our employment
                                                       including health research and measuring the
practices or in the delivery of Services on the
                                                       quality of care and Services. We are sometimes
basis of age, race, color, national origin, cultural
                                                       required by law to give PHI to government
background, religion, sex, sexual orientation, or
                                                       agencies or in judicial actions. In addition,
physical or mental disability.
                                                       Member-identifiable medical information is
                                                       shared with your Group only with your
Notices
                                                       authorization or as otherwise permitted by law.
Our notices to you will be sent to the most recent     We will not use or disclose your PHI for any
address we have for the Subscriber. The                other purpose without your (or your
Subscriber is responsible for notifying us of any      representative’s) written authorization, except as
change in address. Subscribers who move should         described in our Notice of Privacy Practices (see
call our Member Service Call Center as soon as         below). Giving us authorization is at your
possible to report the address change. If you are a    discretion.
Kaiser Permanente Senior Advantage Member,
you should also call the Social Security               This is only a brief summary of some of our
Administration toll free at 800-772-1213 (TTY          key privacy practices. Our Notice of Privacy
users call 800-325-0778). If a Member does not         Practices describing our policies and
reside with the Subscriber, he or she should           procedures for preserving the confidentiality
contact our Member Service Call Center to              of medical records and other PHI is available
discuss alternate delivery options.                    and will be furnished to you upon request. To
                                                       request a copy, please call our Member
Other DF/EOC formats                                   Service Call Center. You can also find the
You can request a copy of this DF/EOC in an            notice at your local Plan Facility or on our
alternate format (Braille, audio, electronic text      Web site at kp.org.
file, or large print) by calling our Member
Service Call Center.                                   Public policy participation
                                                       The Kaiser Foundation Health Plan, Inc., Board
Overpayment recovery                                   of Directors establishes public policy for Health
We may recover any overpayment we make for             Plan. A list of the Board of Directors is available
Services from anyone who receives such an              on our Web site at kp.org or from our Member
overpayment or from any person or organization         Service Call Center. If you would like to provide
obligated to pay for the Services.                     input about Health Plan public policy for
                                                       consideration by the Board, please send written
Privacy practices                                      comments to:
Kaiser Permanente will protect the privacy of              Kaiser Foundation Health Plan, Inc.
your protected health information (PHI). We also           Office of Board and Corporate Governance
require contracting providers to protect your PHI.         Services


156
   One Kaiser Plaza, 19th Floor                   to communicate by phone, you can use the
   Oakland, CA 94612                              California Relay Service by calling 711 if a
                                                  dedicated TTY number is not available for the
Telephone access (TTY)                            telephone number that you want to call.
If you are hearing or speech impaired and use a
text telephone device (TTY, also known as TDD)




                                                                                                    Part Three




                                                                                              157
PLAN FACILITIES

At most of our Plan Facilities, you can usually       Please refer to Your Guidebook for the types of
receive all the covered Services you need,            covered Services that are available from each
including specialty care, pharmacy, and lab work.     Plan Facility in your area, because some facilities
You are not restricted to a particular Plan           provide only specific types of covered Services.
Facility, and we encourage you to use the facility    Additional Plan Medical Offices are listed in
that will be most convenient for you:                 Your Guidebook and on our Web site at kp.org.
• All Plan Hospitals provide inpatient Services
  and are open 24 hours a day, seven days a           This list is subject to change at any time without
  week                                                notice. If you have any questions about the
                                                      current locations of Plan Facilities, please call our
• Emergency Care is available from Plan               Member Service Call Center.
  Hospital Emergency Departments as described
  in Your Guidebook (please refer to Your
                                                      Northern California Region
  Guidebook for Emergency Department
                                                      Plan Facilities
  locations in your area)
• Same-day Urgent Care appointments are               Alameda
  available at many locations (please refer to        • Medical Offices:
  Your Guidebook for Urgent Care locations in           2417 Central Ave
  your area)                                          Antioch
• Many Plan Medical Offices have evening and
                                                      • Hospital and Medical Offices:
  weekend appointments
                                                        4501 Sand Creek Road
• Many Plan Facilities have a Member Services
                                                      • Medical Offices:
  Department (refer to Your Guidebook for
                                                        3400 Delta Fair Blvd
  locations in your area)
                                                      Campbell
• Most Plan Medical Offices include pharmacy
  Services                                            • Medical Offices:
                                                        220 E. Hacienda Ave
Plan Hospitals and Plan Medical Offices               Clovis

The following is a list of Plan Hospitals and most    • Medical Offices:
Plan Medical Offices in the Service Area of our         2071 Herndon Ave
Northern and Southern California Regions. As a        Daly City
Member, you are enrolled in one of two Health         • Medical Offices:
Plan Regions in California (either our Northern         395 Hickey Blvd
California Region or Southern California              Davis
Region), called your Home Region. The coverage
information in this DF/EOC applies when you           • Medical Offices:
obtain care in your Home Region. When you visit         1955 Cowell Blvd
the other California Region, you may receive care     Elk Grove
from Plan Facilities in that Region as described in   • Medical Offices:
“Visiting Other Regions” in the “How to Obtain          9201 Big Horn Blvd
Services” section.



158
Fairfield                         • Please refer to Your Guidebook for other Plan
                                    Providers in Stanislaus County
• Medical Offices:
                                  Mountain View
  1550 Gateway Blvd
Folsom                            • Medical Offices:
                                    555 Castro St
• Medical Offices:
                                  Napa
  2155 Iron Point Road
Fremont                           • Medical Offices:
                                    3285 Claremont Way
• Hospital and Medical Offices:
                                  Novato
  39400 Paseo Padre Parkway
Fresno                            • Medical Offices:
                                    97 San Marin Drive
• Hospital and Medical Offices:
                                  Oakhurst
  7300 N. Fresno St
Gilroy                            • Medical Offices:
                                    40595 Westlake Drive
• Medical Offices:
                                  Oakland
  7520 Arroyo Circle
                                  • Hospital and Medical Offices:




                                                                                    Part Three
Hayward
                                    280 W. MacArthur Blvd
• Hospital and Medical Offices:
                                  Petaluma
  27400 Hesperian Blvd
Lincoln                           • Medical Offices:
                                     3900 Lakeville Highway
• Medical Offices:
                                  Pinole
  1900 Dresden Drive
Livermore                         • Medical Offices:
                                     1301 Pinole Valley Rd.
• Medical Offices:
                                  Pleasanton
  3000 Las Positas Road
Manteca                           • Medical Offices:
                                    7601 Stoneridge Drive
• Hospital and Medical Offices:
                                  Rancho Cordova
  1777 W. Yosemite Ave
• Medical Offices:                • Medical Offices:
  1721 W. Yosemite Ave              10725 International Drive
Martinez                          Redwood City

• Medical Offices:                • Hospital and Medical Offices:
  200 Muir Road                     1150 Veterans Blvd
Milpitas                          Richmond

• Medical Offices:                • Hospital and Medical Offices:
  770 E. Calaveras Blvd             901 Nevin Ave
Modesto                           Rohnert Park

• Hospital and Medical Offices:   • Medical Offices:
  4601 Dale Road                    5900 State Farm Drive
• Medical Offices:
  3800 Dale Road


                                                                              159
Roseville                                      • Medical Office:
                                                 7373 West Ln
• Hospital and Medical Offices:
                                               Tracy
  1600 Eureka Road
• Medical Offices:                             • Medical Offices:
  1001 Riverside Ave                             2185 W. Grant Line Road
Sacramento                                     Turlock

• Hospitals and Medical Offices:               • Hospital:
  2025 Morse Ave and 6600 Bruceville Road        825 Delbon Ave
                                                 (Emanuel Medical Center)
• Medical Offices:
                                               Union City
  1650 Response Road and 2345 Fair Oaks Blvd
San Bruno                                      • Medical Offices:
                                                 3553 Whipple Road
• Medical Offices:
                                               Vacaville
  901 El Camino Real
San Francisco                                  • Medical Offices:
                                                 1 Quality Drive
• Hospital and Medical Offices:
                                               Vallejo
  2425 Geary Blvd
San Jose                                       • Hospital and Medical Offices:
                                                 975 Sereno Drive
• Hospital and Medical Offices:
                                               Walnut Creek
  250 Hospital Parkway
San Rafael                                     • Hospital and Medical Offices:
                                                 1425 S. Main St
• Hospital and Medical Offices:
  99 Montecillo Road                           • Medical Offices:
                                                 320 Lennon Ln
• Medical Offices:
  1033 3rd St
                                               Southern California Region
Santa Clara
                                               Plan Facilities
• Hospital and Medical Offices:
                                               Aliso Viejo
  700 Lawrence Expressway
Santa Rosa                                     • Medical Offices:
                                                 24502 Pacific Park Drive
• Hospital and Medical Offices:
                                               Anaheim
   401 Bicentennial Way
Selma                                          • Hospital and Medical Offices:
                                                 441 N. Lakeview Ave
• Medical Offices:
  2651 Highland Ave                            • Medical Offices: 411 N. Lakeview Ave, 5475
South San Francisco                              E. La Palma Ave, and 1188 N. Euclid St
                                               Bakersfield
• Hospital and Medical Offices:
   1200 El Camino Real                         • Hospitals:
Stockton                                         2615 Chester Ave. (San Joaquin Community
                                                 Hospital)
• Hospital:
  525 W. Acacia St (Dameron Hospital)


160
• Medical Offices:                            Downey
  1200 Discovery Drive, 3501 Stockdale
                                              • Medical Offices:
  Highway, 3700 Mall View Road, 4801 Coffee
                                                 9449 E. Imperial Highway
  Road, and 8800 Ming Ave
                                              El Cajon
Baldwin Park
                                              • Medical Offices:
• Hospital and Medical Offices:
                                                1630 E. Main St
  1011 Baldwin Park Blvd
                                              Escondido
Bellflower
                                              • Hospital:
• Hospital and Medical Offices:
                                                555 E. Valley Parkway (Palomar Medical
  9400 E. Rosecrans Ave
                                                Center)
Bonita
                                              • Medical Offices:
• Medical Offices:                              732 N. Broadway St
  3955 Bonita Road                            Fontana
Brea
                                              • Hospital and Medical Offices:
• Medical Offices:                              9961 Sierra Ave
  1900 E. Lambert Road




                                                                                               Part Three
                                              Garden Grove
Camarillo
                                              • Medical Offices:
• Medical Offices:                              12100 Euclid St
  2620 E. Las Posas Road                      Gardena
Carlsbad
                                              • Medical Offices:
• Medical Offices:                              15446 S. Western Ave
  6860 Avenida Encinas                        Glendale
Chino
                                              • Medical Offices:
• Medical Offices:                              444 W. Glenoaks Blvd
  11911 Central Ave                           Harbor City
Claremont
                                              • Hospital and Medical Offices:
• Medical Offices:                              25825 S. Vermont Ave
  250 W. San Jose St                          Huntington Beach
Colton
                                              • Medical Offices:
• Medical Offices:                              18081 Beach Blvd
  789 S. Cooley Drive                         Indio
Corona
                                              • Hospital:
• Medical Offices:                              47111 Monroe St (John F. Kennedy Memorial
  2055 Kellogg Ave                              Hospital)
Cudahy
                                              • Medical Offices:
• Medical Offices:                              81-719 Doctor Carreon Blvd
  7825 Atlantic Ave                           Inglewood
Culver City
                                              • Medical Offices:
• Medical Offices:                              110 N. La Brea Ave
  5620 Mesmer Ave



                                                                                         161
Irvine                                            Montebello
• Hospital and Medical Offices:                   • Medical Offices:
  6640 Alton Parkway                                1550 Town Center Drive
• Medical Offices:                                Moreno Valley
  6 Willard St                                    • Medical Offices:
Joshua Tree                                         12815 Heacock St
• Hospital:                                       Murrieta
  6601 White Feather Road                         • Hospital:
  (Hi-Desert Medical Center)                        25500 Medical Center Drive (Rancho Springs
• Please refer to Your Guidebook for other Plan     Medical Center)
  Providers in the Yucca Valley-Twentynine        Oceanside
  Palms area
                                                  • Medical Offices:
La Mesa                                             3609 Ocean Ranch Blvd
• Medical Offices:                                Ontario
  8080 Parkway Drive and
                                                  • Medical Offices:
  3875 Avocado Blvd
                                                    2295 S. Vineyard Ave
La Palma
                                                  Oxnard
• Medical Offices:
                                                  • Medical Offices:
  5 Centerpointe Drive
                                                    2200 Gonzales Road
Lancaster
                                                  Palm Desert
• Hospitals:
                                                  • Medical Offices:
  1600 W. Avenue J (Antelope Valley Hospital)
                                                    75-036 Gerald Ford Drive
  and
                                                  Palm Springs
  43830 N. 10th St W. (Lancaster Community
  Hospital)                                       • Hospital:
• Medical Offices:                                  1150 N. Indian Canyon Drive (Desert
  43112 N. 15th St W.                               Regional Medical Center)
Long Beach                                        • Medical Offices:
                                                    1100 N. Palm Canyon Drive
• Medical Offices:
                                                  Palmdale
  3900 E. Pacific Coast Highway
Los Angeles                                       • Medical Offices:
                                                    4502 E. Avenue S
• Hospitals and Medical Offices:
                                                  Panorama City
  1526 N. Edgemont St and
  6041 Cadillac Ave                               • Hospital and Medical Offices:
• Medical Offices:                                  13652 Cantara St
  5119 E. Pomona Blvd and 12001 W.                Pasadena
  Washington Blvd                                 • Medical Offices:
Mission Viejo                                       3280 E. Foothill Blvd
• Medical Offices:
  23781 Maquina Ave



162
Rancho Cucamonga                             Santa Clarita
• Medical Offices:                           • Medical Offices:
  10850 Arrow Route and                        27107 Tourney Road
  10787 Laurel St                            Simi Valley
Redlands
                                             • Medical Offices:
• Medical Offices:                             3900 Alamo St
  1301 California St.                        Temecula
Rancho Mirage
                                             • Medical Offices:
• Hospital:                                    27309 Madison Ave.
  39000 Bob Hope Drive (Eisenhower Medical   Thousand Oaks
  Center)
                                             • Medical Offices:
Riverside
                                               365 E. Hillcrest Drive and 145 Hodencamp
• Hospital and Medical Offices:                Road
  10800 Magnolia Ave                         Torrance
San Bernardino
                                             • Medical Offices:
• Hospital:                                    20790 Madrona Ave




                                                                                                Part Three
  2101 N. Waterman Ave. (Saint Bernadine     Ventura
  Medical Center)
                                             • Hospital:
• Medical Offices:                             147 N. Brent St (Community Memorial
  1717 Date Place                              Hospital of San Buenaventura)
San Diego
                                             • Medical Offices:
• Hospital and Medical Offices:                888 S. Hill Road
  4647 Zion Ave                              Victorville
• Medical Offices:                           • Medical Offices:
  3250 Wing St,                                14011 Park Ave
  4405 Vandever Ave, 4650 Palm Ave, 7060     West Covina
  Clairemont Mesa Blvd, and 11939 Rancho
  Bernardo Road                              • Medical Offices:
San Dimas                                      1249 Sunset Ave
                                             Whittier
• Medical Offices:
  1255 W. Arrow Highway                      • Medical Offices:
San Juan Capistrano                            12470 Whittier Blvd
                                             Wildomar
• Medical Offices:
  30400 Camino Capistrano                    • Hospital:
San Marcos                                     36485 Inland Valley Drive (Inland Valley
                                               Medical Center)
• Medical Offices:
                                             • Medical Offices:
  400 Craven Road
                                               36450 Inland Valley Drive
Santa Ana
                                             Woodland Hills
• Medical Offices:
                                             • Hospital and Medical Offices:
  3401 S. Harbor Blvd and 1900 E. 4th St
                                               5601 De Soto Ave



                                                                                          163
• Medical Offices:                                     Your Guidebook to Kaiser Permanente
  21263 Erwin St                                       Services (Your Guidebook)
Yorba Linda
                                                       Plan Medical Offices and Plan Hospitals for your
• Medical Offices:                                     area are listed in greater detail in Your Guidebook
  22550 E. Savi Ranch Parkway                          to Kaiser Permanente Services (Your
                                                       Guidebook). Your Guidebook describes the types
Note: State law requires evidence of coverage          of covered Services that are available from each
documents to include the following notice:             Plan Facility in your area, because some facilities
“Some hospitals and other providers do not             provide only specific types of covered Services.
provide one or more of the following services          It includes additional facilities that are not listed
that may be covered under your plan contract and       in this “Plan Facilities” section. Also, it explains
that you or your family member might need:             how to use our Services and make appointments,
family planning; contraceptive services, including     lists hours of operation, and includes a detailed
emergency contraception; sterilization, including      telephone directory for appointments and advice.
tubal ligation at the time of labor and delivery;      Your Guidebook provides other important
infertility treatments; or abortion. You should        information, such as preventive care guidelines
obtain more information before you enroll. Call        and your Member rights and responsibilities.
your prospective doctor, medical group,                Your Guidebook is subject to change and is
independent practice association, or clinic, or call   periodically updated. We mail it annually and
the Kaiser Permanente Member Service Call              you can get a copy by visiting our Web site at
Center, to ensure that you can obtain the health       kp.org or by calling our Member Service Call
care services that you need.”                          Center.

Please be aware that if a Service is covered but
not available at a particular Plan Facility, we will
make it available to you at another facility.




164
DEFINITIONS

When capitalized and used in any part of this         • For all other Services, the payments that
DF/EOC, these terms have the following                  Kaiser Permanente makes for the Services (or,
meanings:                                               if Kaiser Permanente subtracts a Copayment or
                                                        Coinsurance from its payment, the amount
Allowance: A specified credit amount that you           Kaiser Permanente would have paid if it did
can use toward the purchase price of an item. If        not subtract a Copayment or Coinsurance)
the price of the item(s) you select exceeds the
Allowance, you will pay the amount in excess of       Clinically Stable: You are considered Clinically
the Allowance (and that payment does not apply        Stable when your treating physician believes,
toward your annual out-of-pocket maximum).            within a reasonable medical probability and in
                                                      accordance with recognized medical standards,
ASH Plans: American Specialty Health Plans of         that you are safe for discharge or transfer and that
California, Inc., a specialized health care service   your condition is not expected to get materially
plan that contracts with licensed chiropractors in    worse during or as a result of the discharge or
California.                                           transfer.




                                                                                                             Part Three
Centers for Medicare & Medicaid Services              Coinsurance: A percentage of Charges that you
(CMS): The Centers for Medicare & Medicaid            must pay when you receive a covered Service as
Services is the federal agency that administers the   described in the “Benefits, Copayments, and
Medicare program.                                     Coinsurance” section.

Charges: Charges means the following:                 Copayment: A specific dollar amount that you
• For Services provided by the Medical Group          must pay when you receive a covered Service as
  or Kaiser Foundation Hospitals, the charges in      described in the “Benefits, Copayments, and
  Health Plan’s schedule of Medical Group and         Coinsurance” section. Note: The dollar amount of
  Kaiser Foundation Hospitals charges for             the Copayment can be $0 (no charge).
  Services provided to Members
• For Services for which a provider (other than       Coverage Determination: An initial
  the Medical Group or Kaiser Foundation              determination we make about whether a Part D
  Hospitals) is compensated on a capitation           drug prescribed for you is covered under Part D
  basis, the charges in the schedule of charges       and the amount, if any, you are required to pay
  that Kaiser Permanente negotiates with the          for the prescription. In general, if you bring your
  capitated provider                                  prescription for a Part D drug to a Plan Pharmacy
                                                      and the pharmacy tells you the prescription isn't
• For items obtained at a pharmacy owned and          covered by us, that isn't a coverage determination.
  operated by Kaiser Permanente, the amount           You need to call or write us to ask for a formal
  the pharmacy would charge a Member for the          decision about the coverage if you disagree.
  item if a Member’s benefit plan did not cover
  the item (this amount is an estimate of: the
                                                      Dependent: A Member who meets the eligibility
  cost of acquiring, storing, and dispensing
                                                      requirements as a Dependent (for Dependent
  drugs, the direct and indirect costs of
                                                      eligibility requirements, see “Eligibility” in the
  providing Kaiser Permanente pharmacy
                                                      “Premiums, Eligibility, and Enrollment” section).
  Services to Members, and the pharmacy
  program’s contribution to the net revenue
  requirements of Health Plan)


                                                                                                      165
Emergency Care:                                      Medical Group: For Northern California Region
• Evaluation by a physician (or other appropriate    Members, The Permanente Medical Group, Inc.,
  personnel under the supervision of a physician     a for-profit professional corporation, and for
  to the extent provided by law) to determine        Southern California Region Members, the
  whether you have an Emergency Medical              Southern California Permanente Medical Group,
  Condition                                          a for-profit professional partnership.
• Medically Necessary Services required to           Medically Necessary: A Service is Medically
  make you Clinically Stable within the              Necessary if it is medically appropriate and
  capabilities of the facility
                                                     required to prevent, diagnose, or treat your
• Emergency ambulance Services covered under         condition or clinical symptoms in accord with
  “Ambulance Services” in the “Benefits,             generally accepted professional standards of
  Copayments, and Coinsurance” section               practice that are consistent with a standard of care
                                                     in the medical community.
Emergency Medical Condition: Either (1) a
medical or psychiatric condition that manifests      Medicare: A federal health insurance program
itself by acute symptoms of sufficient severity      for people age 65 and older and some people
(including severe pain) such that you could          under age 65 with disabilities or end-stage renal
reasonably expect the absence of immediate           disease (permanent kidney failure). In this
medical attention to result in serious jeopardy to   DF/EOC, Members who are “eligible for”
your health or body functions or organs; or          Medicare Part A or B are those who would
(2) active labor when there isn’t enough time for    qualify for Medicare Part A or B coverage if they
safe transfer to a Plan Hospital (or designated      applied for it. Members who are “entitled to” or
hospital) before delivery or if transfer poses a     “have” Medicare Part A or B are those who have
threat to your (or your unborn child’s) health and   been granted Medicare Part A or B coverage.
safety.                                              Also, a person enrolled in a Medicare Part D plan
                                                     has Medicare Part D by virtue of his or her
Family: A Subscriber and all of his or her           enrollment in the Part D plan (this DF/EOC is a
Dependents.                                          Part D plan).

Group: California Public Employees Retirement        Medicare Advantage Organization: A public or
System (CalPERS).                                    private entity organized and licensed by a state as
                                                     a risk-bearing entity that has a contract with CMS
Health Plan: Kaiser Foundation Health Plan,          to provide Services covered by Medicare, except
Inc., a California nonprofit corporation. This       for hospice care and clinical trials covered by
DF/EOC sometimes refers to Health Plan as “we”       Original Medicare. Kaiser Foundation Health
or “us.”                                             Plan, Inc., is a Medicare Advantage Organization.

Home Region: The Northern California Region          Medicare Advantage Plan: Sometimes called
or Southern California Region where you are          Medicare Part C. A plan offered by a private
enrolled.                                            company that contracts with Medicare to provide
                                                     you with all your Medicare Part A (Hospital) and
Kaiser Permanente: Kaiser Foundation                 Part B (Medical) benefits. Medicare Advantage
Hospitals (a California nonprofit corporation),      Plans may also offer Medicare Part D
Health Plan, and the Medical Group.                  (prescription drug coverage). This DF/EOC is a
                                                     Medicare Part D plan.


166
Medigap (Medicare Supplement Insurance)                Out-of-Area Urgent Care: Medically Necessary
Policy: Medicare supplement insurance sold by          Services to prevent serious deterioration of your
private insurance companies to fill “gaps” in the      (or your unborn child’s) health resulting from an
Original Medicare plan coverage. Medigap               unforeseen illness, unforeseen injury, or
policies only work with the Original Medicare          unforeseen complication of an existing condition
plan. (A Medicare Advantage Plan is not a              (including pregnancy) if all of the following are
Medigap policy.)                                       true:
                                                       • You are temporarily outside your Home
Member: A person who is eligible and enrolled            Region’s Service Area
under this DF/EOC, and for whom we have
received applicable Premiums. This DF/EOC              • You reasonably believed that your (or your
sometimes refers to a Member as “you.”                   unborn child’s) health would seriously
                                                         deteriorate if you delayed treatment until you
                                                         returned to your Home Region’s Service Area
Non–Plan Hospital: A hospital other than a Plan
Hospital.
                                                       Plan Facility: Any facility listed in the “Plan
Non–Plan Pharmacy: A pharmacy other than a             Facilities” section or in a Kaiser Permanente
Plan Pharmacy. These pharmacies are also called        guidebook (Your Guidebook) for your Home
                                                       Region’s Service Area, except that Plan Facilities




                                                                                                              Part Three
“out-of-network pharmacies.”
                                                       are subject to change at any time without notice.
Non–Plan Physician: A physician other than a           For the current locations of Plan Facilities, please
Plan Physician.                                        call our Member Service Call Center.

Non–Plan Provider: A provider other than a             Plan Hospital: Any hospital listed in the “Plan
Plan Provider.                                         Facilities” section or in a Kaiser Permanente
                                                       guidebook (Your Guidebook) for your Home
                                                       Region’s Service Area, except that Plan Hospitals
Non–Plan Skilled Nursing Facility: A Skilled
                                                       are subject to change at any time without notice.
Nursing Facility other than a Plan Skilled
                                                       For the current locations of Plan Hospitals, please
Nursing Facility.
                                                       call our Member Service Call Center.
Organization Determination: An initial
                                                       Plan Medical Office: Any medical office listed
determination we make about whether we will
                                                       in the “Plan Facilities” section or in a Kaiser
cover or pay for Part C Services that you believe
                                                       Permanente guidebook (Your Guidebook) for
you should receive.
                                                       your Home Region’s Service Area, except that
                                                       Plan Medical Offices are subject to change at any
Original Medicare (“Traditional Medicare” or
                                                       time without notice. For the current locations of
“Fee-for-Service Medicare”): The Original
                                                       Plan Medical Offices, please call our Member
Medicare plan is the way many people get their
                                                       Service Call Center.
health care coverage. It is the national pay-per-
visit program that lets you go to any doctor,
                                                       Plan Optical Sales Office: An optical sales
hospital, or other health care provider that accepts
                                                       office owned and operated by Kaiser Permanente
Medicare. You must pay a deductible. Medicare
                                                       or another optical sales office that we designate.
pays its share of the Medicare approved amount,
                                                       Please refer to Your Guidebook for a list of Plan
and you pay your share. Original Medicare has
                                                       Optical Sales Offices in your area, except that
two parts: Part A (Hospital Insurance) and Part B
                                                       Plan Optical Sales Offices are subject to change
(Medical Insurance), and is available everywhere
                                                       at any time without notice. For the current
in the United States and its territories.



                                                                                                       167
locations of Plan Optical Sales Offices, please        physician selection department at the phone
call our Member Service Call Center.                   number listed in Your Guidebook.

Plan Pharmacy: A pharmacy owned and                    Region: A Kaiser Foundation Health Plan
operated by Kaiser Permanente or another               organization or allied plan that conducts a direct-
pharmacy that we designate. Please refer to Your       service health care program. For information
Guidebook for a list of Plan Pharmacies in your        about Region locations in the District of
area, except that Plan Pharmacies are subject to       Columbia and parts of Southern and Northern
change at any time without notice. For the current     California, Colorado, Georgia, Hawaii, Idaho,
locations of Plan Pharmacies, please call our          Maryland, Ohio, Oregon, Virginia, and
Member Service Call Center.                            Washington, please call our Member Service Call
                                                       Center.
Plan Physician: Any licensed physician who is a
partner or employee of the Medical Group, or any       Service Area: Health Plan has two Regions in
licensed physician who contracts to provide            California: the Northern California Region and
Services to Members (but not including                 the Southern California Region. As a Member
physicians who contract only to provide referral       enrolled under the CalPERS Agreement, you are
Services).                                             enrolled in one of the two California Regions.
                                                       This DF/EOC describes the coverage of both
Plan Provider: A Plan Hospital, a Plan                 California Regions.
Physician, the Medical Group, a Plan Pharmacy,
or any other health care provider that we              Please refer to the “Service Area” section for the
designate as a Plan Provider.                          description your Home Region’s Service Area.

Plan Skilled Nursing Facility: A Skilled               Services: Health care services or items.
Nursing Facility approved by Health Plan.
                                                       Skilled Nursing Facility: A facility that provides
Post-Stabilization Care: Medically Necessary           inpatient skilled nursing care, rehabilitation
Services related to your Emergency Medical             services, or other related health services and is
Condition that you receive after your treating         licensed by the state of California. The facility’s
physician determines that this condition is            primary business must be the provision of 24-
Clinically Stable.                                     hour-a-day licensed skilled nursing care. The
                                                       term “Skilled Nursing Facility” does not include
Premiums: Periodic membership charges paid by          convalescent nursing homes, rest facilities, or
your Group.                                            facilities for the aged, if those facilities furnish
                                                       primarily custodial care, including training in
Primary Care Physicians: Generalists in                routines of daily living. A “Skilled Nursing
internal medicine, pediatrics, and family practice,    Facility” may also be a unit or section within
and specialists in obstetrics/gynecology whom          another facility (for example, a hospital) as long
the Medical Group designates as Primary Care           as it continues to meet this definition.
Physicians. Please refer to our Web site at kp.org
for a list of Primary Care Physicians, except that     Spouse: Your legal husband or wife. For the
the list is subject to change without notice. For      purposes of this DF/EOC, the term “Spouse”
the current list of physicians that are available as   includes your registered domestic partner who
Primary Care Physicians, please call the personal      meets all of the requirements of Section 297 of
                                                       the California Family Code, or your domestic


168
partner in accord with your Group’s              “Eligibility” in the “Premiums, Eligibility, and
requirements.                                    Enrollment” section).

Subscriber: A Member who is eligible for         Urgent Care: Medically Necessary Services for
membership on his or her own behalf and not by   a condition that requires prompt medical attention
virtue of Dependent status and who meets the     but is not an Emergency Medical Condition.
eligibility requirements as a Subscriber (for
Subscriber eligibility requirements, see




                                                                                                      Part Three




                                                                                                169
SERVICE AREA

Northern California Region                            Napa: 94503, 94508, 94515, 94558–59, 94562,
Service Area                                          94567*, 94573–74, 94576, 94581, 94589–90,
The following counties are entirely inside our        94599, 95476
Northern California Region’s Service Area:            Placer: 95602–04, 95626, 95648, 95650, 95658,
Alameda, Contra Costa, Marin, Sacramento, San         95661, 95663, 95668, 95677–78, 95681, 95692,
Francisco, San Joaquin, San Mateo, Solano, and        95703, 95722, 95736, 95746–47, 95765
Stanislaus.
                                                      Santa Clara: 94022–24, 94035, 94039–43,
Portions of the counties listed below are also        94085–89, 94301–06, 94309, 94550, 95002,
inside our Northern California Region’s Service       95008–09, 95011, 95013–15, 95020–21, 95026,
Area as indicated by the ZIP codes below for          95030–33, 95035–38, 95042, 95044, 95046,
each county. A ZIP code is considered to be           95050–56, 95070–71, 95076, 95101, 95103,
inside our Service Area only if it is in the county   95106, 95108–13, 95115–36, 95138–41, 95148,
associated with that ZIP code. For example, since     95150–61, 95164, 95170, 95172–73, 95190–94,
a ZIP code can span more than one county, even        95196
if your ZIP code is listed below, your home is not    Sonoma: 94515, 94922–23, 94927–28, 94931,
inside our Service Area if you live in a county       94951–55, 94972, 94975, 94999, 95401–07,
that is not part of our Service Area. Also, the ZIP   95409, 95416, 95419, 95421, 95425, 95430–31,
codes listed below may include ZIP codes for          95433, 95436, 95439, 95441–42, 95444, 95446,
Post Office boxes and commercial rental               95448, 95450, 95452, 95462, 95465, 95471–73,
mailboxes. A Post Office box or rental mailbox        95476, 95486–87, 95492
cannot be used to determine whether you meet          Sutter: 95626, 95645, 95648, 95659, 95668,
the residence eligibility requirements for Senior     95674, 95676, 95692, 95836–37
Advantage. Your permanent residence address           Tulare: 93238, 93261, 93618, 93631, 93646,
must be used to determine your Senior Advantage       93654, 93666, 93673
eligibility:
                                                      Yolo: 95605, 95607, 95612, 95616–18, 95645,
Amador: 95640, 95669                                  95691, 95694–95, 95697–98, 95776, 95798–99
El Dorado: 95613–14, 95619, 95623, 95633–35,          Yuba: 95692, 95903, 95961
95651, 95664, 95667, 95672, 95682, 95762
Fresno: 93242, 93602, 93606–07, 93609, 93611–         *Exception: Knoxville is not in our Northern
13, 93616, 93618–19, 93624–27, 93630–31,              California Region’s Service Area.
93646, 93648–52, 93654, 93656–57, 93660,
93662, 93667–68, 93675, 93701–12, 93714–18,           Southern California Region
93720–30, 93741, 93744–45, 93747, 93750,              Service Area
93755, 93760–61, 93764–65, 93771–80, 93784,           Orange County is entirely inside our Southern
93786, 93790–94, 93844, 93888                         California Region’s Service Area.
Kings: 93230, 93232, 93242, 93631, 93656
                                                      Portions of the counties listed below are also
Madera: 93601–02, 93604, 93614, 93623,
                                                      inside our Southern California Region’s Service
93626, 93636–39, 93643–45, 93653, 93669,
                                                      Area as indicated by the ZIP codes below for
93720
                                                      each county. A ZIP code is considered to be
Mariposa: 93601, 93623, 93653                         inside our Service Area only if it is in the county

170
  Member Service Call Center: 800-464-4000 (TTY 800-777-1370) 7 a.m.–7 p.m., weekdays and 7
                                   a.m.–3 p.m. weekends)


associated with that ZIP code. For example, since     91780, 91788–93, 91795, 91801–04, 91896,
a ZIP code can span more than one county, even        93243, 93510, 93532, 93534–36, 93539, 93543–
if your ZIP code is listed below, your home is not    44, 93550–53, 93560, 93563, 93584, 93586,
inside our Service Area if you live in a county       93590–91, 93599
that is not part of our Service Area. Also, the ZIP
                                                      Riverside: 91752, 92201–03, 92210–11, 92220,
codes listed below may include ZIP codes for
                                                      92223, 92230, 92234–36, 92240–41, 92247–48,
Post Office boxes and commercial rental
                                                      92253, 92255, 92258, 92260–64, 92270, 92276,
mailboxes. A Post Office box or rental mailbox
                                                      92282, 92292, 92320, 92324, 92373, 92399,
cannot be used to determine whether you meet
                                                      92501–09, 92513–19, 92521–22, 92530–32,
the residence eligibility requirements for Senior
                                                      92543–46, 92548, 92551–57, 92562–64, 92567,
Advantage. Your permanent residence address
                                                      92570–72, 92581–87, 92589–93, 92595–96,
must be used to determine your Senior Advantage
                                                      92599, 92860, 92877–83
eligibility:
                                                      San Bernardino: 91701, 91708–10, 91729–30,
                                                      91737, 91739, 91743, 91758, 91761–64, 91766,
Kern: 93203, 93205–06, 93215–16, 93220,
                                                      91784–86, 91792, 92305, 92307–08, 92313–18,
93222, 93224–26, 93238, 93240–41, 93243,
                                                      92321–22, 92324–26, 92329, 92331, 92333–37,




                                                                                                        Part Three
93250–52, 93263, 93268, 93276, 93280, 93285,
                                                      92339–41, 92344–46, 92350, 92352, 92354,
93287, 93301–09, 93311–14, 93380–90, 93501–
                                                      92357–59, 92369, 92371–78, 92382, 92385–86,
02, 93504–05, 93518–19, 93531, 93536, 93560–
                                                      92391–95, 92397, 92399, 92401–08, 92410–15,
61, 93581
                                                      92418, 92423–24, 92427, 92880
Los Angeles: 90001–84, 90086–89, 90091,
                                                      San Diego: 91901–03, 91908–17, 91921, 91931–
90093–96, 90101, 90103, 90189, 90201–02,
                                                      33, 91935, 91941–47, 91950–51, 91962–63,
90209–13, 90220–24, 90230–33, 90239–42,
                                                      91976–80, 91987, 92007–11, 92013–14, 92018–
90245, 90247–51, 90254–55, 90260–67, 90270,
                                                      27, 92029–30, 92033, 92037–40, 92046, 92049,
90272, 90274–75, 90277–78, 90280, 90290–96,
                                                      92051–52, 92054–58, 92064–65, 92067–69,
90301–12, 90401–11, 90501–10, 90601–10,
                                                      92071–72, 92074–75, 92078–79, 92081–85,
90623, 90630–31, 90637–40, 90650–52, 90660–
                                                      92090–93, 92096, 92101–24, 92126–32, 92134-
62, 90670–71, 90701–03, 90706–07, 90710–17,
                                                      40, 92142–43, 92145, 92147, 92149–50, 92152–
90723, 90731–34, 90744–49, 90755, 90801–10,
                                                      55, 92158–79, 92182, 92184, 92186–87, 92190–
90813–15, 90822, 90831–35, 90840, 90842,
                                                      99
90844, 90846–48, 90853, 90895, 91001, 91003,
91006–12, 91016–17, 91020–21, 91023–25,               Ventura: 90265, 91304, 91307, 91311, 91319–
91030–31, 91040–43, 91046, 91066, 91077,              20, 91358–62, 91377, 93001–07, 93009–12,
91101–10, 91114–18, 91121, 91123–26, 91129,           93015–16, 93020–22, 93030–36, 93040–44,
91182, 91184–85, 91188–89, 91199, 91201–10,           93060–66, 93093–94, 93099, 93252
91214, 91221–22, 91224–26, 91301–11, 91313,
91316, 91321–22, 91324–31, 91333–35, 91337,           Note: Subject to approval by the Centers for
91340–46, 91350–57, 91361-62, 91364–65,               Medicare & Medicaid Services (CMS), we may
91367, 91371–72, 91376, 91380–81, 91383–88,           reduce our Southern California Region’s or
91390, 91392–96, 91401–13, 91416, 91423,              Northern California Region’s Service Area
91426, 91436, 91470, 91482, 91495–96, 91499,          effective any January 1 by giving prior written
91501–08, 91510, 91521–23, 91601–12, 91614–           notice to your Group. We may expand our
18, 91702, 91706, 91709, 91711, 91714–16,             Southern California Region’s or Northern
91722–24, 91731–35, 91740–41, 91744–50,               California Region’s Service Area at any time by
91754–56, 91759, 91765–73, 91775–76, 91778,           giving written notice to your Group. ZIP codes



                                                                                                  171
are subject to change by the U.S. Postal Service.
If you have a question about whether a ZIP code
is currently in your Home Region’s Service Area,
please call our Member Service Call Center.




172
APPENDIX - PREVENTIVE SCREENINGS AND VACCINES

At Kaiser Permanente, one way we help you enjoy a long, healthy life is by providing you guidelines on
how to help prevent illness. Below is an overview of screening tests and immunizations vaccines that are
recommended. For more information about the guidelines, as well as recommended lifestyle practices,
please refer to Your Guidebook to Kaiser Permanente Services, or visit our Web site at kp.org.

The preventive care guidelines listed below are based on the medical evidence available and are subject to
change. The guidelines are for generally healthy people. If you have ongoing health problems, if certain
conditions run in your family, or if you have other special health needs or risks, you may need a
personalized prevention plan. Talk with your physician about a guideline that fits your needs.

This document does not describe coverage for preventive care services. To learn about coverage, please
refer to your DF/EOC.

Children and Teens
 Screening tests                      Frequency




                                                                                                               Part Three
 Height and weight                    Every well-check visit. Starting at age 3, body mass index (BMI)
                                      may be calculated to help determine if your child is at a healthy
                                      weight.
 Hearing                              Once on all newborns, and then periodically as recommended by a
                                      physician, through age 17.
 Blood pressure                       Every well check visit starting at age 3.
 Thyroid activity, galactose          Testing at birth for thyroid deficiencies, intolerance to milk sugar
 metabolism disorder, hemoglobin      (galactosemia), sickle cell disease and other hemoglobin diseases,
 (blood) disorders, and               and PKU. Additional tests, as needed, for problems such as high
 phenylketonuria (PKU)                cholesterol, tuberculosis, anemia, or lead exposure.
 Vision                               Vision screening beginning at age 3, and then periodically as
                                      recommended by your physician.
 Cervical cancer (for women)          Pap test at least every three years starting at age 21, or earlier if
                                      sexually active.
 Chlamydia                            Annual chlamydia test for sexually active women age 25 or younger.

 Vaccines                             Frequency
 General                              Vaccine schedule is subject to change based on Centers for Disease
                                      Control and Prevention and American Academy of Pediatrics
                                      recommendations.
 Diphtheria, tetanus, and pertussis   One dose at 2, 4, 6, and 12 to 18 months, at 4 to 6 years, and Tdap
 (DTaP)                               (tetanus, diphtheria, and pertussis) at 11 to 12 years.
 Haemophilus influenza type B         One dose at 2 and 4 months. Booster at 12 to 15 months.
 Hepatitis A                          Two doses at least 6 months apart for all children 1 through 18 years.
 Hepatitis B                          Three doses given between age 2 and 15 months. First dose may be
                                      given at birth if given in a combination with DTaP and polio. Catch-
                                      up vaccination: Three doses if not previously vaccinated.




                                                                                                         173
Vaccines                      Frequency
Human papillomavirus (HPV)    Three doses at 11 to 12 years up to age 26. Catch-up vaccination:
                              Three doses, if not previously vaccinated, up to age 18.
Influenza                     One shot annually starting between ages 2 and 6 months.
Measles, mumps, and rubella   One dose at 12 to 18 months and at 4 to 6 years.
Meningococcal                 One dose starting at 11 years. Booster may be indicated depending on
                              which vaccination is used.
Polio                         One dose at 2, 4, and 6 months, and at 4 to 6 years.
Pneumococcus                  One dose at 2, 4, and 6 months. Booster at 12 to 15 months.
Rotavirus                     One dose at 2, 4, and 6 months.
Varicella                     One dose between 12 and 15 months and a second dose at 4-6 years.
                              Catch-up vaccination: Two doses if immunity is not present.

Adults
Screening tests               Frequency
Height and weight             Body mass index (BMI) calculated at health care visits.
Blood pressure                Blood pressure checked at every health care visit. Blood pressure
                              goal is 139/89 or lower.
Cholesterol                   Get tested every 5 years starting at age 35 for men and age 45 for
                              women.
Diabetes                      Get tested every five years starting at age 45 - 50, or in adults with
                              hyperlipidemia (LDL > 130) and hypertension (blood pressure
                              >139/89 mmHg), regardless of age.
Cervical cancer (for women)   Get a Pap test at least every three years starting at age 21, or earlier if
                              sexually active. Beginning at age 30, have a Pap and human
                              papilloma virus (HPV) test every three years up to age 65.
Prostate cancer (for men)     Discuss the prostate-cancer screening specific antigen (PSA) test and
                              rectal exam with your physician starting in your 40’s.
Chlamydia                     Annual chlamydia test for all sexually active women age 25 or
                              younger.
Colorectal cancer             Flexible sigmoidoscopy at least every 10 years and/or a fecal occult
                              blood test annually starting at age 50. Colonoscopy may also be
                              recommended by your health care provider in certain clinical
                              situations.
Breast cancer (for women)     Mammograms are recommended every one to two years between
                              ages 50 and 69. For women age 40 to 49 and for women aged 70 and
                              older, mammography is offered in the context of a shared decision-
                              making approach, taking into consideration life expectancy, patient
                              preference, comorbidities, and clinician judgment.
HIV and other sexually        Testing for HIV and other STDs for adults with risk factors (e.g.,
transmitted diseases (STDs)   unprotected sex, pregnancy, or other risk factors). Sexually active
                              women should have a chlamydia test annually through age 25.
Osteoporosis                  Bone mineral density (BMD) test for postmenopausal women aged
                              65 and older who are not on drug treatment for osteoporosis.




174
Vaccines       Frequency
Tetanus        One-dose Td booster every 10 years.
Influenza      Annual flu shot for all adults aged 50 and older or if you have a
               chronic health condition like asthma, diabetes, heart or kidney
               disease, or a weakened immune system due to other conditions or
               medications. Be vaccinated if you care for or live with someone with
               one of the conditions listed above or with a child under 5 years of
               age.
Pneumococcus   Pneumonia vaccination at age 65.




                                                                                      Part Three




                                                                               175
Northern California
Legend:
n Kaiser Permanente
   medical centers
   (hospital and
   medical offices)

● Kaiser Permanente
   medical offices

   Affiliated plan
   hospitals

   Affiliated medical
   offices

                                                          Sierra Nevada
                                                            Mountains
                                                                                                              China Lake
                                                                                                        Naval Weapons Center




                        Maps not to scale


                                                                              Fresno County area

                                            Kern County area
                                              Tehachapi
                                              Mountains




Southern California                                                       Edwards Air Force Base




Legend:
n Kaiser Permanente
   medical centers                                                                                                     San Bernardino
                                                                                                                       National Forest

   (hospital and
   medical offices)                                                                                                                  San Bernardino
                                                                                                                                       Mountains



● Kaiser Permanente
   medical offices

   Affiliated plan
   hospitals
                                                                                        Cleveland
                                                                                      National Forest


                                                                                                                                                 San Jacinto
                                                                                                                                                  Mountains


                                                                                                                        San Bernardino
                                                                                                                        National Forest


                                                                                                                                                                    Santa R
                                                                                                                                                                    Mount




                                                                                                                                                                        An




                        Maps not to scale
                                                                                                                                                    Cleveland
                                                                                                                                                  National Forest

				
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