2011 July Conversion Plans Southern California by mmcsx

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									2011 CONVERSION PLANS CALIFORNIA
                 SOUTHERN
TABLE OF CONTENTS
                                   Stay with your plan for good health                                                 1
                                   Our conversion plans offer a simple way to stay with the health plan you trust.

                                   Choosing the right plan                                                             2
                                   Copay or deductible plan? It’s your choice.

                                   Benefit highlights                                                                  3
                                   An overview of benefits for the Kaiser Permanente Conversion
                                   Copayment 25 plan and the Kaiser Permanente Conversion
                                   Deductible 30/1500 plan

                                   Your 2011 rates                                                                     4
                                   Our service areas                                                                   5
                                   Your service area helps determine your monthly rate.

                                   Frequently asked questions                                                          6
                                   Answers to commonly asked questions about Kaiser Permanente
                                   conversion plan membership

                                   How to apply                                                                        8
                                   Simple step-by-step instructions for submitting your enrollment application

                                   Enrollment application                                                              9
                                   Plan details                                                                      11
                                   The Membership Agreements contain an explanation of benefits and coverage,
                                   including exclusions and limitations in detail for our plans.

                                   Reply envelope                                                 Inside front cover
                                   A pre-addressed, postage-paid envelope for
                                   returning your enrollment application

Note:
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.

語言翻譯協助
提供每週七天,每天廿四小時翻譯。我們也向會員及其親友提供利用我處設施及服務所需之任何協助。此外會員還可索取以
其母語編寫的資料。若需更多資訊,請於週一至週五上午七時至下午七時及週末上午七時至下午三時致電會員服務電話中
心,電話號碼為 1-800-757-7585 或 1-800-777-1370 (聽障專線)。
STAY WITH YOUR PLAN FOR GOOD HEALTH
          When it comes to your health care, you’ve got a good
          thing going.
          So keep it going strong. Make the easy move to one of our conversion plans and
          there won’t be any surprises. You can feel secure knowing that you can still access
          all the advantages you’ve come to rely on.

          These include the same quality, service, and convenience you’ve enjoyed up to now:

          n   Choice of great doctors
          n   Full access to medical offices and hospitals across the region
          n   24-hour telephone advice from registered nurses
          n   Local classes and online programs to help you get—and stay—healthy
          n   Electronic health records to help your doctors keep current with your
              health needs

          Stay well connected
          Our conversion plans offer a simple way to stay with the health plan you know.
          When you enroll in a conversion plan, you can keep your personal physician, with
          no lapse in coverage. And, if you have children, they can keep their pediatrician.

          You’ll also retain your members-only access to My Health Manager at kp.org.
          This secure online feature enables you to schedule routine appointments, refill
          most prescriptions, and view certain health records—all at a time that’s convenient
          for you.

          Go with the flow of good health – it’s easy!
          To keep your doctor, your easy online access, and other advantages you’ve come to
          depend on, simply follow the steps outlined on “How to Apply” on page 8 to select
          the conversion plan of your choice.

          Taking steps to ensure continuous coverage is one of the most important things you
          can do for yourself and your family. So be sure to sign your completed enrollment
          form to avoid a delay in processing. Remember, you must return your complete
          application within 30 days of receiving this booklet.

          We’re glad you’re looking to stay with Kaiser Permanente. May you continue to live
          well and thrive.




                                                                                                1
CHOOSING THE RIGHT PLAN
    Two conversion plans                                       Factors affecting your rate
    Our two conversion plans offer subscriber-only             We are committed to providing you with continued
    coverage. Families may still apply to enroll in our        coverage at competitive rates for all the quality health
    plans—but each family member will be enrolled in his       care benefits available to you. The monthly rate you
    or her own plan.                                           pay for your coverage depends on your plan, your age
                                                               on July 1, 2011, and where you live. If you change plans
    Family members do not have to apply to enroll in           or move to a new residence and change ZIP codes,
    the same plan. This allows you to select different         your monthly rate will change on the month following
    plans for different family members, depending on           your change.
    their needs.
                                                               Finding your rate(s):
    For example, you may select the extra coverage
    offered by the Conversion Copayment 25 plan for                n   Locate your ZIP code in the listing on page 5
    young children. But perhaps you might choose the                   to determine your rate area.
    less expensive Conversion Deductible 30/1500
    plan for yourself. The choice is yours.
                                                                   n   Turn to the rate charts on page 4 and find your
                                                                       rate area.
    We encourage you to apply to enroll all your family
    members in a conversion plan to avoid any lapse
                                                                   n   Find your age in the chart.
    in coverage. Once you have coverage established,               n   Now locate the desired plan in the top row.
    you or your family members may submit a medical
    review form and apply for one of our Kaiser                    n   Your rate will appear in the box where the column
    Permanente for Individuals and Families (KPIF)                     and row intersect.
    plans, which offer a broader selection of benefits.
                                                               Repeat these steps for each family member
                                                               applying for coverage. Then add the rates for all
                                                               family members to determine your combined
                                                               monthly premium.

                                                               Please note: If your ZIP code does not appear on
                                                               page 5, contact our Member Service Call Center at
                                                               1-800-464-4000 for information on other rate areas.




                                         QUESTIONS?
                                                           visit   kp.org
2
BENEFIT HIGHLIGHTS
Health plan benefits and coverage comparison chart for the Kaiser Permanente Conversion
Copayment 25 and the Conversion Deductible 30/1500 plans

To assist you in choosing your health coverage, we’ve provided an overview of benefits and copayments for both
the Conversion Copayment 25 and the Conversion Deductible 30/1500 plans. This overview is intended to help
you compare coverage benefits and is a summary only. Please refer to the Membership Agreements for a detailed
description of copayments and coinsurance.

                                                                       COPAYMENT 25                              DEDUCTIBlE 30/1500
Features
  Annual deductible                                                            None                                             $1,500
  Annual out-of-pocket maximum                                                $2,500                                            $3,500
Benefits                                                            Services not subject to deductible unless otherwise indicated
Preventive care
  Immunizations                                                                                      No charge
  Routine physical exam                                                                              No charge
  Well-child visit (0–23 months)                                                                     No charge
  Well-woman visit                                                                                   No charge
  Mammogram (screening)                                                                              No charge
Outpatient services (per visit or procedure)
  Primary care/Specialty office visit                                        $25 copay                                         $30 copay
  Most X-rays and lab tests                                                  $10 copay                              $10 copay (after deductible)
  MRI, CT, and PET                                                           $50 copay                              $50 copay (after deductible)
  Outpatient surgery                                                        $100 copay                             $250 copay (after deductible)
Inpatient hospital care

  Room and board, surgery, anesthesia, X-rays, lab tests,                                                               $500 copay per day
                                                                         $200 copay per day
  and medication                                                                                                         (after deductible)
Maternity                                                                Coverage varies. Please consult the plan’s Membership Agreement.
  Maternity care                                                              Covered                                Covered (after deductible)
Emergency and urgent care
  Emergency Department visit (waived if admitted)                           $100 copay                             $150 copay (after deductible)
  Urgent care visit                                                          $25 copay                                         $30 copay
  Ambulance service                                                         $100 copay                             $150 copay (after deductible)
Prescription drugs
  Plan pharmacy (up to a 30-day supply)                                                  Generic: $10 copay/Brand: $35 copay
  Mail-order (up to a 100-day supply)                                                    Generic: $20 copay/Brand: $70 copay




                                                            OR CALL Us At
                                                                               1-800-464-4000
                                                                                                                                                   3
MONTHLY RATES
                         Rate Area 2                  Rate Area 3                Rate Area 4                Rate Area 5
      Age on
    July 1, 2011   Copayment     Deductible     Copayment     Deductible   Copayment     Deductible   Copayment     Deductible
                      25          30/1500          25          30/1500        25          30/1500        25          30/1500
        <1           $720          $520           $758          $547         $795          $574          $833         $603
       1–18            360           260            379           273          397           287          416           300
        19             379           272            399           285          419           300          440           314
        20             404           289            425           304          447           319          469           334
        21             426           306            448           321          470           336          494           353
        22             448           319            470           334          494           351          518           368
        23             467           331            493           348          516           365          542           382
        24             484           343            510           360          535           379          561           397
        25             503           355            530           374          557           392          583           411
        26             518           367            545           385          574           406          601           425
        27             535           379            562           399          591           419          618           438
        28             550           391            579           411          608           433          637           453
        29             567           401            596           423          627           443          656           465
        30             581           413            612           433          642           455          673           477
        31             596           421            627           443          657           465          690           487
        32             610           430            642           453          674           476          707           498
        33             620           438            652           460          685           484          717           508
        34             625           447            659           470          691           494          725           518
        35             632           455            666           479          698           503          732           527
        36             639           460            673           484          705           510          739           533
        37             646           469            680           493          712           518          746           542
        38             651           474            686           499          720           525          754           549
        39             657           481            693           506          727           530          761           555
        40             664           486            700           511          734           537          770           562
        41             671           493            707           518          742           544          776           571
        42             678           499            714           527          749           552          785           579
        43             685           510            720           535          756           562          793           589
        44             691           520            727           547          765           574          800           601
        45             698           530            736           557          771           586          809           613
        46             705           544            742           572          780           601          817           630
        47             714           555            753           584          790           615          827           644
        48             724           569            763           600          800           629          839           659
        49             736           583            775           613          812           644          851           674
        50             746           600            785           632          826           663          865           695
        51             761           615            802           647          841           680          882           712
        52             776           630            817           663          858           697          899           729
        53             792           646            834           680          875           714          918           748
        54             807           661            851           697          894           731          936           766
        55             833           678            877           714          919           749          963           785
        56             856           693            902           731          948           766          992           804
        57             884           707            929           744          975           782        1,023           819
        58             909           720            957           758        1,004           797        1,054           834
        59             933           736            980           775        1,030           814        1,079           851
        60             933           736            980           775        1,030           814        1,079           851
        61             933           736            980           775        1,030           814        1,079           851
        62             933           736            980           775        1,030           814        1,079           851
        63             933           736            980           775        1,030           814        1,079           851
        64             933           736            980           775        1,030           814        1,079           851
       65+           1,791         1,791          1,885         1,885        1,978         1,978        2,074         2,074


                                              QUESTIONS?
                                                               visit    kp.org
4
SERvICE AREA ZIP CODES
Rate Area 2
90004–39       90311–12       91023–25       91214          91921          92049          92142–43       92623–30   92811–12   93015–16
90041–51       90401–11       91030–31       91221–22       91931–33       92051–52       92145          92637      92814–17   93022
90053–57       90620–24       91046          91224–26       91935          92054–61       92147          92646–63   92821–23   93030–36
90060          90630–33       91066          91501–08       91941–47       92064–65       92149–50       92672–79   92825      93040–44
90062–76       90637–39       91077          91510          91950–51       92067–69       92152–55       92683–85   92831–38   93060–61
90078–84       90680          91101–10       91521–23       91962–63       92071–72       92158–79       92688      92840–46   93066
90086–90       90720–21       91114–18       91709          91976–80       92074–75       92182          92690–94   92850
90093–96       90740          91121          91754          91987          92078–79       92184          92697–98   92856–57
90189          90742–43       91123–26       91756          92003          92081–86       92186–87       92701–08   92859
90209–13       90895          91129          91775          92007–11       92088          92190–94       92711–12   92861
90230–33       91001          91182          91780          92013–14       92091–93       92195–99       92728      92863–71
90245          91003          91184–85       91801–04       92018–30       92096          92602–07       92735      92885–87
90272          91006–12       91188–89       91896          92033          92101–24       92609–10       92780–82   92899
90291–96       91016–17       91199          91901–03       92037–40       92126–32       92612          92799      93001–07
90301–09       91020–21       91201–10       91908–17       92046          92134–40       92614–20       92801–09   93009–12


Rate Area 3
90001–03       90247–51       90640          90801–10       91708          91761–73       92320–22       92369      92427      92581–87
90040          90254–55       90650–52       90813–15       91710–11       91776          92324–26       92371–78   92501–09   92589–93
90052          90260–62       90660–62       90822          91714–16       91778          92329          92382      92513–19   92595–96
90058–59       90266–67       90670–71       90831–35       91722–24       91784–86       92331          92385–86   92521–22   92599
90061          90270          90701–03       90840          91729–35       91788–93       92333–37       92391–95   92530–32   92860
90091          90274–75       90706–07       90842          91737          91795          92339–41       92397      92543–46   92877–83
90101          90277–78       90710–17       90844          91739–41       92220          92344–46       92399      92548
90103          90280          90723          90846–48       91743–50       92223          92350          92401–08   92551–57
90201–02       90310          90731–34       90853          91752          92305          92352          92410–15   92562–64
90220–24       90501–10       90744–49       91701–02       91755          92307–08       92354          92418      92567
90239–42       90601–10       90755          91706          91758–59       92313–18       92357–59       92423–24   92570–72


Rate Area 4
90077          91324–31       91376–77       91426          93020–21       93222          93268          93383–90   93543–44   93599
90263–65       91333–35       91380–81       91436          93062–65       93224–26       93276          93501–02   93550–53
90290          91337          91383–87       91470          93094          93238          93280          93504–05   93560–61
91040–43       91340–46       91390          91482          93099          93240–41       93285          93510      93563
91301–11       91350–62       91392–96       91495–96       93203          93243          93287          93518–19   93581
91313          91364–65       91401–13       91499          93205–06       93249–52       93301–09       93531–32   93584
91316          91367          91416          91601–12       93215–16       93261          93311–14       93534–36   93586
91319–22       91371–72       91423          91614–18       93220          93263          93380          93539      93590–91



Rate Area 5
92201–03       92230          92240–41        92252–56      92260–64       92270          92282           92292
92210–11       92234–36       92247–48        92258         92268          92274–78       92284–86
Rate Area 5 also includes Southern California members who live outside our Southern California service areas




                                                        OR CALL Us At
                                                                                  1-800-464-4000
                                                                                                                                          5
FREqUENTLY ASKED qUESTIONS
The following questions are those most commonly            If my account terminates, how do I request
asked by our members about their Kaiser Permanente         reinstatement?
coverage. Look them over, and if you need more             You can contact us at 1-888-236-4490 to request
information or have any additional questions, feel         reinstatement on a terminated account. A representative
free to call our Member Service Call Center at             will be happy to review your account to determine if
1-800-464-4000 from 7 a.m. to 7 p.m., weekdays,            your account is eligible for reinstatement.
and 7 a.m. to 3 p.m., weekends (except holidays).
                                                           When is my health plan premium due?
What will my rate be?                                      Be sure that your monthly payment is received on
Your rate is based on the cost of care for the             or before the last day of the month preceding
specific combination of benefits covered by the            coverage. For example, to be eligible for the month
Kaiser Permanente health plan you choose. Your rate        of January, full payment must be received on or before
also depends upon your address and age as of               December 31. Late payment may result in termination
July 1, 2011. Please refer to the “Monthly Rates”          of your health care coverage.
section to find your rate.
                                                           Make your check or money order payable to Kaiser
What is the major difference between the                   Foundation Health Plan, Inc., and write your account
Conversion Copayment 25 and the Conversion                 number (found on the remittance portion of your
Deductible 30/1500 plans?                                  monthly statement) on the check. Do not send post-
n The Conversion Copayment 25 does not have a              dated checks or cash. Checks returned by the bank
  deductible. Members can pay a copayment for              are subject to a $25 fee.
  covered services from the first day of coverage.
n The Conversion Deductible 30/1500 has a $1,500           Each billing statement shows the amount you need
  deductible for most covered services.                    to pay for each month and the date it is due. Please
                                                           return the remittance portion of the statement with
Can I add a dependent to an existing                       each payment. Please include the remittance portion
conversion plan?                                           and payment only. Use a separate envelope for
No. Except for newborns and newly adopted children,        payments for any family members who have
dependents are not eligible for enrollment in a            Medicare billing statements.
conversion plan unless they were enrolled when you
became a conversion plan subscriber.                       Do not write on the face of the remittance portion of
                                                           the statement. If you have comments or questions,
When you first enroll in a conversion plan, you may        please write them on a separate page and include
apply to enroll yourself, just your children, or your      your name, subscriber’s signature, account number or
entire family. Each of your family members will be         medical record number, and daytime phone number
enrolled under his or her own plan at a separate rate.     with area code. Comments and questions should not
This allows you to easily select different plans for       be mailed with your payment. Please mail them to the
different family members. For example, you may want        correspondence address at the bottom of page 7.
the extra coverage of our Conversion Plan 25 for a
young child, but you might like the lower premiums of
our Conversion Deductible Plan 30/1500 for yourself.




                                      QUESTIONS?
                                                         visit   kp.org
6
FREqUENTLY ASKED qUESTIONS

Can I make payments using an ATM/debit card or            How do I sign up for consolidated billing?
credit card?                                              Call the Member Service Call Center at
Yes. If you choose to pay by credit card, debit card,     1-800-464-4000 to request a Consolidated Billing
or bank account, you may register and make payments       Authorization Form. Please continue to pay using your
online at kp.org/payonline. If you pay by credit card,    regular bills until you receive the new consolidated bill.
debit card, or check, you may also make payments
over the phone. Simply call us at 1-800-403-5945.         How do I make address or name changes to
You will need a copy of your most recent bill on          an account?
hand, along with your bank account or credit card         n To change your address, call 1-800-464-4000 to
information, when utilizing this option. Accepted           request an Address Change Form. Complete and
credit cards are visa, MasterCard, American Express,        return the form to the Direct Pay correspondence
and Discover.                                               address below.
                                                          n To change a name on your account, please send

How can I elect to make payments using                      a written request, including the signature of the
electronic funds transfer?                                  subscriber or person with the name change, to the
Call the Member Service Call Center at 1-800-464-4000       Direct Pay correspondence address below.
or write to the correspondence address below to
request an Electronic Funds Transfer Form. Please         Direct Pay correspondence address
continue to pay as you normally would until the           Use the following address to:
transfer is in effect.                                    n Request additional information
                                                          n Request address changes

Do I have a grace period?                                 n Add a dependent

No, unless you elect electronic funds transfer. Kaiser    n Request name changes

Permanente is a prepaid health care plan, and             n Remove a dependent

payments are due on or before the first of the month
preceding the month of coverage. However, if you            Kaiser Permanente
elect electronic funds transfer, we withdraw funds from     Direct Pay Correspondence
your bank on the fifth day of the month of coverage.        P.O. Box 23127
                                                            San Diego, CA 92193-3127
Can I make payment arrangements?
No. Kaiser Permanente does not accept partial
payments or make payment arrangements.

Can I make one payment for multiple accounts?
Yes, through a service called consolidated billing.
Consolidated billing allows multiple subscriber
accounts to receive a single bill.

Who is eligible for consolidated billing?
Consolidated billing is designed for two or more
subscribers who live in the same region and would
like to receive a single bill. Please note that
Northern and Southern California accounts
cannot be combined.




                                            OR CALL Us At
                                                                   1-800-464-4000
                                                                                                                       7
HOW TO APPLY


                              1
                                        You have two conversion plan options from which to choose.
                                          n Conversion Copayment 25
                                          n Conversion Deductible 30/1500


                                        Rates and benefits vary depending on the plan. See the benefit comparison
                                        chart on page 3 to help determine which plan is best for you. In addition, please
                                        review the Membership Agreements for more details.




                              2
                                        Complete Sections A and B of the enrollment application. Check the box at
                                        the top of the application to select the plan you are applying for. Be sure to
                                        complete all required fields to ensure we have your current information for
                                        membership, including your medical record number. Each family member will
                                        need to complete a separate application.




                              3
                                        Keep a copy of your completed and signed application(s) for your records.




                              4
                                        Return the application in the enclosed postage-paid envelope or fax it to
                                        (858) 614-3345.

                                           Our mailing address is:
                                           Kaiser Permanente
                                           P.O. Box 23127
                                           San Diego, CA 92193-3127




When your conversion plan application is received and processed, we will send your first bill in the mail. All payments
are due by the 1st of each month. If we approve your enrollment application, we will send you billing information within
30 days after we receive your application. You will have 45 days to pay the bill.
Please note: If you choose to apply and are accepted for the Kaiser Permanente Conversion Copayment 25 plan, you
may change to the Kaiser Permanente Conversion Deductible 30/1500 plan at a later date. However, if you choose to
apply and are accepted for the Conversion Deductible 30/1500 plan, you will not be able to change to the Conversion
Copayment 25 plan after 30 days following your effective date.



8
                                                                        Conversion Plan Enrollment Application
Please print in ink only. Please see the instructions on page 8 before                     Please check the plan you are applying for:
completing this form. Each family member must submit a separate application.               o Conversion Copayment 25
                                                                                           o Conversion Deductible 30/1500

  A. APPLICANT INFORMATION
  _______________________________________________________________________________________
  Last name                                  First name                      MI
  ________ /________ /________     Gender: o Male o Female        Marital status: o Married o Single
  Date of birth
           –         –
  ____________________________________________________________________________________________________________
  Social Security number           Medical record number          Current family account number
   ____________________________________________________________________________________________________________
   Home address (no P.O. Boxes please)                         City                        State    ZIP
  ____________________________________________________________________________________________________________
  Mailing address (if different than above) or P.O. Box
  (      )                              (        )
  ____________________________________________________________________________________________________________
  Day phone r Home r Work               Evening phone r Home r Work


  B. GROUP SUBSCRIBER INFORMATION
  _______________________________________________________________
  Group subscriber name
  _______________________________________________________________                     __________________________________________
  Company or trust fund name                                                          Purchaser number
  _______________________________________________________________
  Relation to applicant
  _______________________________________________________________
  Mailing address if different from applicant’s
  Reason for conversion request
  o Termination of employment                Last day employed: _____/_____/_______
  o Loss of dependent status due to:         o Marriage o Divorce o Overage o Other _________________________________
  Purchaser coverage ends on: _____/_____/_______
  Please note: To qualify for a conversion plan, you must have no lapse in coverage.


Kaiser Foundation Health Plan Arbitration Agreement:
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in
coverage that is subject to the ERISA claims procedure regulation (29 CFR 2560.503-1), certain benefit-related disputes), any dispute
between myself, my heirs, relatives, or other associated parties on the one hand and Health Plan, its health care providers, or
other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in Health Plan,
including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were
improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or
items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court
process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial
and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Membership Agreement.


 X                                                                                                                               q
Applicant/Financially responsible party                                                       Today’s date

Important: Required signatures—all Applicants age 18 or over must sign and date above on the appropriate signature line (financially responsible
party, spouse, dependent). Parent or legal guardian must sign for dependents under the age of 18. Use ink only.
Return application by fax to (858) 614-3345, or mail to Kaiser Permanente, P.O. Box 23127, San Diego, CA 92193-3127.




                                                                                                                                               9
Kaiser Foundation Health Plan, Inc.
Southern California Region

A nonprofit corporation


Individual Plan Membership Agreement and
Disclosure Form and Evidence of Coverage for
Kaiser Permanente Individual—Conversion Plan


Copayment 25 Plan




Highlights
Copayments and Coinsurance
Most consultations and exams.......................              $25 per visit
Hospital inpatient care...................................       $200 per day
Outpatient surgery .........................................     $100 per procedure
Emergency Department visits .......................              $100 per visit
Generic drugs ................................................   $10 for up to a 30-day supply
Brand-name drugs .........................................       $35 for up to a 30-day supply




                                                                     Member Service Call Center
                                                                     Weekdays 7 a.m.–7 p.m.; weekends 7 a.m.–3 p.m.
                                                                     (except holidays)
                                                                     1-800-464-4000 toll free
                                                                     1-800-777-1370 (toll free TTY for the hearing/speech impaired)
                                                                     kp.org
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.




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VERSION_DESCRIPTION MANUAL C1V3 2011 RENEWAL RATES FID 39142374 TAMMYS X7977
REASON_FOR_NEW_VERSION RENEWED
VER_REN_DATE 01/01/2011
TABLE OF CONTENTS
Health Plan Benefits and Coverage Matrix .......................................................................................................................... 1
Introduction .......................................................................................................................................................................... 3
   Term of this Membership Agreement and Evidence of Coverage, Renewal, and Amendment........................................ 3
   About Kaiser Permanente................................................................................................................................................. 4
Definitions............................................................................................................................................................................ 4
Premiums, Eligibility, and Enrollment ................................................................................................................................. 7
   Premiums.......................................................................................................................................................................... 7
   Who Is Eligible................................................................................................................................................................. 8
   How to Enroll ................................................................................................................................................................... 9
How to Obtain Services........................................................................................................................................................ 9
   Routine Care..................................................................................................................................................................... 9
   Urgent Care .................................................................................................................................................................... 10
   Not Sure What Kind of Care You Need? ....................................................................................................................... 10
   Your Personal Plan Physician ........................................................................................................................................ 10
   Getting a Referral ........................................................................................................................................................... 10
   Second Opinions ............................................................................................................................................................ 12
   Contracts with Plan Providers ........................................................................................................................................ 12
   Visiting Other Regions................................................................................................................................................... 13
   Your ID Card.................................................................................................................................................................. 13
   Getting Assistance.......................................................................................................................................................... 13
Plan Facilities ..................................................................................................................................................................... 14
   Plan Hospitals and Plan Medical Offices ....................................................................................................................... 14
   Your Guidebook to Kaiser Permanente Services (Your Guidebook).............................................................................. 17
Emergency Services and Urgent Care................................................................................................................................ 17
   Emergency Services ....................................................................................................................................................... 17
   Urgent Care .................................................................................................................................................................... 18
   Payment and Reimbursement ......................................................................................................................................... 18
Benefits and Cost Sharing .................................................................................................................................................. 19
   Cost Sharing ................................................................................................................................................................... 20
   Preventive Care Services................................................................................................................................................ 21
   Outpatient Care .............................................................................................................................................................. 22
   Hospital Inpatient Care................................................................................................................................................... 23
   Ambulance Services....................................................................................................................................................... 23
   Bariatric Surgery ............................................................................................................................................................ 24
   Chemical Dependency Services ..................................................................................................................................... 24
   Dental and Orthodontic Services.................................................................................................................................... 25
   Dialysis Care .................................................................................................................................................................. 26
   Durable Medical Equipment for Home Use ................................................................................................................... 26
   Health Education ............................................................................................................................................................ 28
   Hearing Services ............................................................................................................................................................ 28
   Home Health Care.......................................................................................................................................................... 28
   Hospice Care .................................................................................................................................................................. 29
   Mental Health Services .................................................................................................................................................. 29
   Ostomy and Urological Supplies.................................................................................................................................... 31
   Outpatient Imaging, Laboratory, and Special Procedures .............................................................................................. 31
   Outpatient Prescription Drugs, Supplies, and Supplements ........................................................................................... 32
   Prosthetic and Orthotic Devices ..................................................................................................................................... 34
   Reconstructive Surgery .................................................................................................................................................. 35
   Services Associated with Clinical Trials ........................................................................................................................ 35
  Skilled Nursing Facility Care ......................................................................................................................................... 36
  Transplant Services ........................................................................................................................................................ 36
  Vision Services............................................................................................................................................................... 37
Exclusions, Limitations, Coordination of Benefits, and Reductions .................................................................................. 37
  Exclusions ...................................................................................................................................................................... 37
  Limitations ..................................................................................................................................................................... 40
  Coordination of Benefits ................................................................................................................................................ 40
  Reductions...................................................................................................................................................................... 40
Dispute Resolution ............................................................................................................................................................. 42
  Grievances...................................................................................................................................................................... 42
  Supporting Documents ................................................................................................................................................... 43
  Who May File................................................................................................................................................................. 43
  Department of Managed Health Care Complaints.......................................................................................................... 44
  Independent Medical Review (IMR).............................................................................................................................. 44
  Binding Arbitration ........................................................................................................................................................ 45
Termination of Membership............................................................................................................................................... 47
  How You May Terminate Your Membership ................................................................................................................ 47
  Termination Due to Loss of Eligibility .......................................................................................................................... 47
  Termination for Cause.................................................................................................................................................... 47
  Termination for Nonpayment of Premiums.................................................................................................................... 48
  Termination for Discontinuance of a Product ................................................................................................................ 48
  Payments after Termination ........................................................................................................................................... 48
  State Review of Membership Termination..................................................................................................................... 48
Miscellaneous Provisions ................................................................................................................................................... 49
Helpful Information............................................................................................................................................................ 50
  Your Guidebook to Kaiser Permanente Services (Your Guidebook)............................................................................. 50
  How to Reach Us............................................................................................................................................................ 51
  Payment Responsibility.................................................................................................................................................. 51
Health Plan Benefits and Coverage Matrix
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR
A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
Annual Out-of-Pocket Maximum for Certain Services                       $2,500 per calendar year
For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Copayments and
 Coinsurance you pay for those Services add up to this amount.
Deductible or Lifetime Maximum                                                                               None
Professional Services (Plan Provider office visits)                                                          You Pay
Most primary and specialty care consultations and exams..........................                            $25 per visit
Routine physical maintenance exams..........................................................                 No charge
Well-child preventive exams (through age 23 months)...............................                           No charge
Family planning counseling ........................................................................          No charge
Scheduled prenatal care exams and first postpartum follow-up
 consultation and exam...............................................................................        No charge
Eye exams for refraction .............................................................................       No charge
Hearing exams.............................................................................................   No charge
Urgent care consultations and exams ..........................................................               $25 per visit
Physical, occupational, and speech therapy ................................................                  $25 per visit
Outpatient Services                                                                                          You Pay
Outpatient surgery and certain other outpatient procedures ........................                          $100 per procedure
Allergy injections (including allergy serum)...............................................                  $5 per visit
Most immunizations (including vaccines) ..................................................                   No charge
Most X-rays and laboratory tests.................................................................            $10 per encounter
Preventive X-rays, screenings, and laboratory tests as described in the
 "Benefits and Cost Sharing" section..........................................................               No charge
MRI, most CT, and PET scans....................................................................              $50 per procedure
Health education:
   Covered individual health education counseling and programs.............                                  No charge
   Covered group education programs .......................................................                  No charge
Hospitalization Services                                                   You Pay
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs . $200 per day
Emergency Health Coverage                                                                         You Pay
Emergency Department visits ..................................................................... $100 per visit
Note: This Cost Sharing does not apply if admitted directly to the hospital as an inpatient for covered Services (see
 "Hospitalization Services" for inpatient Cost Sharing).
Ambulance Services                                                                                     You Pay
Ambulance Services.................................................................................... $100 per trip
Prescription Drug Coverage                                                                 You Pay
Most covered outpatient items in accord with our drug formulary
 guidelines:
   Generic items from a Plan Pharmacy..................................................... $10 for up to a 30-day supply, $20 for a 31- to 60-
                                                                                            day supply, or $30 for a 61- to 100-day supply
   Generic refills from our mail-order service............................................ $10 for up to a 30-day supply or $20 for a 31- to
                                                                                            100-day supply




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                             Page 1
Prescription Drug Coverage                                                             You Pay
   Brand-name items from a Plan Pharmacy.............................................. $35 for up to a 30-day supply, $70 for a 31- to 60-
                                                                                        day supply, or $105 for a 61- to 100-day supply
   Brand-name refills from our mail-order service..................................... $35 for up to a 30-day supply or $70 for a 31- to
                                                                                        100-day supply
Durable Medical Equipment                                               You Pay
The durable medical equipment for home use listed in the "Benefits and
 Cost Sharing" section in accord with our durable medical equipment
 formulary guidelines (most durable medical equipment is not covered) . 20% Coinsurance
Mental Health Services                                                                                You Pay
Inpatient psychiatric hospitalization and intensive psychiatric treatment
 programs (up to 30 days per calendar year) .............................................. $200 per day
Outpatient mental health evaluations and treatments:
   Up to a total of 20 individual and group visits per calendar year that                             $25 per individual visit
     include Services for mental health evaluation or treatment ................. $12 per group visit
   Up to 20 additional group visits in the same calendar year that meet
     Medical Group criteria ......................................................................... $12 per visit
Note: Visit and day limits do not apply to Serious Emotional Disturbances of children and Severe Mental Illnesses as described
 in the "Benefits and Cost Sharing" section.
Chemical Dependency Services                                                                               You Pay
Inpatient detoxification ...............................................................................   $200 per day
Individual outpatient chemical dependency consultations and treatment ...                                  $25 per visit
Group outpatient chemical dependency treatment ......................................                      $5 per visit
Transitional residential recovery Services (up to 60 days per calendar
 year, not to exceed 120 days in any five-year period)...............................                      $100 per admission
Home Health Services                                                                   You Pay
Home health care (up to 100 visits per calendar year) ................................ No charge
Other                                                                                                        You Pay
Skilled Nursing Facility care (up to 100 days per benefit period)............... No charge
Hospice care................................................................................................ No charge

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




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                         Page 2
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Introduction                                                           Term of this Membership Agreement and
                                                                       Evidence of Coverage, Renewal, and
This Individual Plan Membership Agreement and                          Amendment
Disclosure Form and Evidence of Coverage
(Membership Agreement and Evidence of Coverage)                         Term of this Membership Agreement and
describes the health care coverage of "Kaiser Permanente                Evidence of Coverage
Individual—Conversion Copayment 25 Plan." This                          This Membership Agreement and Evidence of Coverage
Membership Agreement and Evidence of Coverage, the                      becomes effective on the membership effective date in
Rate Sheet which is incorporated into this Membership                   the Subscriber's acceptance letter and will remain in
Agreement and Evidence of Coverage by reference, and                    effect until one of the following occurs:
any amendments, constitute the legally binding contract                 • The Membership Agreement and Evidence of
between Health Plan (Kaiser Foundation Health Plan,                       Coverage is amended as described under
Inc.) and the Subscriber. For benefits provided under any                 "Amendment of Membership Agreement and
other Health Plan program, refer to that plan's evidence                  Evidence of Coverage" in this "Introduction" section
of coverage.
                                                                        • There are no longer any Members in your Family
                                                                          who are covered under this Membership Agreement
In this Membership Agreement and Evidence of
                                                                          and Evidence of Coverage
Coverage, Health Plan is sometimes referred to as "we"
or "us." Members are sometimes referred to as "you."
Some capitalized terms have special meaning in this                     Note: Your membership may terminate even if this
Membership Agreement and Evidence of Coverage;                          Membership Agreement and Evidence of Coverage
please see the "Definitions" section for terms you should               remains in effect for other covered Members of your
know.                                                                   Family. The "Termination of Membership" section
                                                                        explains how membership may terminate.
The "Kaiser Permanente Individual—Conversion Plan"
                                                                        Renewal
does not include dependent coverage, so each person in
your family who is accepted for coverage must enroll as                 If you comply with all the terms of this Membership
a Subscriber under his or her own Membership                            Agreement and Evidence of Coverage, we will
Agreement and Evidence of Coverage as described under                   automatically renew this Membership Agreement and
"Who Is Eligible" and "How to Enroll" in the                            Evidence of Coverage each year, effective on one of the
"Premiums, Eligibility, and Enrollment" section. Any                    following dates:
references in this Membership Agreement and Evidence                    • January 1 if the most recent effective date of the
of Coverage to Dependents, Spouses, or children are not                   Subscriber's coverage is between January 1 and June
applicable to your coverage.                                              30
                                                                        • July 1 if the most recent effective date of the
Please read the following information so that you will
                                                                          Subscriber's coverage is between July 1 and
know from whom or what group of providers you                             December 31
may get health care. It is important to familiarize
yourself with your coverage by reading this Membership
                                                                        Terms of the Membership Agreement and Evidence of
Agreement and Evidence of Coverage completely, so that
                                                                        Coverage will remain the same when we renew it unless
you can take full advantage of your Health Plan benefits.
                                                                        we have amended the Membership Agreement and
Also, if you have special health care needs, please
                                                                        Evidence of Coverage as described under "Amendment
carefully read the sections that apply to you.
                                                                        of Membership Agreement and Evidence of Coverage" in
                                                                        this "Term of this Membership Agreement and Evidence
Note: The Health Plan Benefits and Coverage Matrix is
                                                                        of Coverage, Renewal, and Amendment" section.
located in the front of this Membership Agreement and
Evidence of Coverage.
                                                                        Amendment of Membership Agreement and
                                                                        Evidence of Coverage
                                                                        In accord with "Notices" in the "Miscellaneous
                                                                        Provisions" section, we may amend this Membership
                                                                        Agreement and Evidence of Coverage (including
                                                                        Premiums and benefits) at any time by sending
                                                                        written notice to the Subscriber at least 30 days
                                                                        before the effective date of the amendment. The



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 3
amendment may become effective earlier than the end of       Definitions
the period for which you have already paid your
Premiums, and it may require you to pay additional
                                                             Some terms have special meaning in this Membership
Premiums for that period. All amendments are deemed
                                                             Agreement and Evidence of Coverage. When we use a
accepted by the Subscriber unless the Subscriber gives us
                                                             term with special meaning in only one section of this
written notice of non-acceptance within 30 days of the
                                                             Membership Agreement and Evidence of Coverage, we
date of the notice, in which case this Membership
                                                             define it in that section. The terms in this "Definitions"
Agreement and Evidence of Coverage terminates the day
                                                             section have special meaning when capitalized and used
before the effective date of the amendment.
                                                             in any section of this Membership Agreement and
                                                             Evidence of Coverage.
If we notified the Subscriber that we have not received
all necessary governmental approvals related to this         Charges: "Charges" means the following:
Membership Agreement and Evidence of Coverage, we            • For Services provided by the Medical Group or
may amend this Membership Agreement and Evidence of            Kaiser Foundation Hospitals, the charges in Health
Coverage by giving written notice to the Subscriber after      Plan's schedule of Medical Group and Kaiser
receiving all necessary governmental approval, in accord       Foundation Hospitals charges for Services provided
with "Notices" in the "Miscellaneous Provisions"               to Members
section. Any such government-approved provisions go
into effect on January 1, 2011 (unless the government        • For Services for which a provider (other than the
requires a later effective date).                              Medical Group or Kaiser Foundation Hospitals) is
                                                               compensated on a capitation basis, the charges in the
                                                               schedule of charges that Kaiser Permanente
About Kaiser Permanente                                        negotiates with the capitated provider
                                                             • For items obtained at a pharmacy owned and operated
Kaiser Permanente provides Services directly to our
                                                               by Kaiser Permanente, the amount the pharmacy
Members through an integrated medical care program.
                                                               would charge a Member for the item if a Member's
Health Plan, Plan Hospitals, and the Medical Group
                                                               benefit plan did not cover the item (this amount is an
work together to provide our Members with quality care.
                                                               estimate of: the cost of acquiring, storing, and
Our medical care program gives you access to all of the
                                                               dispensing drugs, the direct and indirect costs of
covered Services you may need, such as routine care
                                                               providing Kaiser Permanente pharmacy Services to
with your own personal Plan Physician, hospital care,
                                                               Members, and the pharmacy program's contribution
laboratory and pharmacy Services, Emergency Services,
                                                               to the net revenue requirements of Health Plan)
Urgent Care, and other benefits described in the
"Benefits and Cost Sharing" section. Plus, our health        • For all other Services, the payments that Kaiser
education programs offer you great ways to protect and         Permanente makes for the Services or, if Kaiser
improve your health.                                           Permanente subtracts Cost Sharing from its payment,
                                                               the amount Kaiser Permanente would have paid if it
We provide covered Services to Members using Plan              did not subtract Cost Sharing
Providers located in our Service Area, which is described    Coinsurance: A percentage of Charges that you must
in the "Definitions" section. You must receive all           pay when you receive a covered Service as described in
covered care from Plan Providers inside our Service          the "Benefits and Cost Sharing" section.
Area, except as described in the sections listed below for
the following Services:                                      Copayment: A specific dollar amount that you must pay
                                                             when you receive a covered Service as described in the
• Authorized referrals as described under "Getting a
                                                             "Benefits and Cost Sharing" section. Note: The dollar
  Referral" in the "How to Obtain Services" section
                                                             amount of the Copayment can be $0 (no charge).
• Emergency ambulance Services as described under
                                                             Cost Sharing: The Copayment or Coinsurance you are
  "Ambulance Services" in the "Benefits and Cost
                                                             required to pay for a covered Service.
  Sharing" section
• Emergency Services, Post-Stabilization Care, and           Deductible: The amount you must pay in a calendar year
  Out-of-Area Urgent Care as described in the                for certain Services before we will cover those Services
  "Emergency Services and Urgent Care" section               at the applicable Copayment or Coinsurance in that
                                                             calendar year.
• Hospice care as described under "Hospice Care" in
  the "Benefits and Cost Sharing" section                    Dependent: A Member who meets the eligibility
                                                             requirements as a Dependent.



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 4
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
Emergency Medical Condition: A medical condition                        accord with generally accepted professional standards of
manifesting itself by acute symptoms of sufficient                      practice that are consistent with a standard of care in the
severity (including severe pain) such that a prudent                    medical community.
layperson, who possesses an average knowledge of
                                                                        Medicare: The federal health insurance program for
health and medicine, could reasonably expect the
                                                                        people 65 years of age or older, some people under age
absence of immediate medical attention to result in any
                                                                        65 with certain disabilities, and people with end-stage
of the following:
                                                                        renal disease (generally those with permanent kidney
• Placing the person's health (or, with respect to a                    failure who need dialysis or a kidney transplant). In this
  pregnant woman, the health of the woman or her                        Membership Agreement and Evidence of Coverage,
  unborn child) in serious jeopardy                                     Members who are "eligible for" Medicare Part A or B are
• Serious impairment to bodily functions                                those who would qualify for Medicare Part A or B
                                                                        coverage if they applied for it. Members who "have"
• Serious dysfunction of any bodily organ or part                       Medicare Part A or B are those who have been granted
                                                                        Medicare Part A or B coverage.
A mental health condition is an Emergency Medical
Condition when it meets the requirements of the                         Member: A person who is eligible and enrolled under
paragraph above, or when the condition manifests itself                 this Membership Agreement and Evidence of Coverage,
by acute symptoms of sufficient severity such that either               and for whom we have received applicable Premiums.
of the following is true:                                               This Membership Agreement and Evidence of Coverage
                                                                        sometimes refers to a Member as "you."
• The person is an immediate danger to himself or
  herself or to others                                                  Membership Agreement and Evidence of Coverage:
                                                                        This Membership Agreement and Disclosure Form and
• The person is immediately unable to provide for, or
                                                                        Evidence of Coverage document, which describes your
  use, food, shelter, or clothing, due to the mental
                                                                        Health Plan coverage. This Membership Agreement and
  disorder
                                                                        Evidence of Coverage, the Rate Sheet which is
Emergency Services: All of the following with respect                   incorporated into this Membership Agreement and
to an Emergency Medical Condition:                                      Evidence of Coverage by reference, and any
                                                                        amendments, constitute the legally binding contract
• A medical screening exam that is within the
                                                                        between Health Plan and the Subscriber.
  capability of the emergency department of a hospital,
  including ancillary services (such as imaging and                     Non–Plan Hospital: A hospital other than a Plan
  laboratory Services) routinely available to the                       Hospital.
  emergency department to evaluate the Emergency
                                                                        Non–Plan Physician: A physician other than a Plan
  Medical Condition
                                                                        Physician.
• Within the capabilities of the staff and facilities
  available at the hospital, Medically Necessary                        Non–Plan Provider: A provider other than a Plan
  examination and treatment required to Stabilize the                   Provider.
  patient (once your condition is Stabilized, Services                  Out-of-Area Urgent Care: Medically Necessary
  you receive are Post Stabilization Care and not                       Services to prevent serious deterioration of your (or your
  Emergency Services)                                                   unborn child's) health resulting from an unforeseen
Family: A Subscriber and all of his or her Dependents.                  illness, unforeseen injury, or unforeseen complication of
                                                                        an existing condition (including pregnancy) if all of the
Health Plan: Kaiser Foundation Health Plan, Inc., a                     following are true:
California nonprofit corporation. This Membership
                                                                        • You are temporarily outside our Service Area
Agreement and Evidence of Coverage sometimes refers
to Health Plan as "we" or "us."                                         • You reasonably believed that your (or your unborn
                                                                          child's) health would seriously deteriorate if you
Kaiser Permanente: Kaiser Foundation Hospitals (a
                                                                          delayed treatment until you returned to our Service
California nonprofit corporation), Health Plan, and the
                                                                          Area
Medical Group.
                                                                        Plan Facility: Any facility listed in the "Plan Facilities"
Medical Group: The Southern California Permanente
                                                                        section or in a Kaiser Permanente guidebook (Your
Medical Group, a for-profit professional partnership.
                                                                        Guidebook) for our Service Area, except that Plan
Medically Necessary: A Service is Medically Necessary                   Facilities are subject to change at any time without
if it is medically appropriate and required to prevent,                 notice. For the current locations of Plan Facilities, please
diagnose, or treat your condition or clinical symptoms in               call our Member Service Call Center.



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 5
Plan Hospital: Any hospital listed in the "Plan               Rate Sheet included with the Subscriber's acceptance
Facilities" section or in a Kaiser Permanente guidebook       letter, unless the Rate Sheet has been amended as
(Your Guidebook) for our Service Area, except that Plan       described under "Term and amendment of this
Hospitals are subject to change at any time without           Membership Agreement and Evidence of Coverage" in
notice. For the current locations of Plan Hospitals, please   the "Introduction" section.
call our Member Service Call Center.
                                                              Region: A Kaiser Foundation Health Plan organization
Plan Medical Office: Any medical office listed in the         or allied plan that conducts a direct-service health care
"Plan Facilities" section or in a Kaiser Permanente           program. For information about Region locations in the
guidebook (Your Guidebook) for our Service Area,              District of Columbia and parts of Northern California,
except that Plan Medical Offices are subject to change at     Colorado, Georgia, Hawaii, Idaho, Maryland, Ohio,
any time without notice. For the current locations of Plan    Oregon, Virginia, and Washington, please call our
Medical Offices, please call our Member Service Call          Member Service Call Center.
Center.
                                                              Service Area: Orange County is entirely inside our
Plan Pharmacy: A pharmacy owned and operated by               Service Area. Portions of the following counties are also
Kaiser Permanente or another pharmacy that we                 inside our Service Area, as indicated by the ZIP codes
designate. Please refer to Your Guidebook for a list of       below for each county:
Plan Pharmacies in your area, except that Plan                • Imperial: 92274–75
Pharmacies are subject to change at any time without
notice. For the current locations of Plan Pharmacies,         • Kern: 93203, 93205–06, 93215–16, 93220, 93222,
please call our Member Service Call Center.                     93224–26, 93238, 93240–41, 93243, 93249–52,
                                                                93263, 93268, 93276, 93280, 93285, 93287, 93301–
Plan Physician: Any licensed physician who is a partner         09, 93311–14, 93380, 93383–90, 93501–02, 93504–
or employee of the Medical Group, or any licensed               05, 93518–19, 93531, 93536, 93560–61, 93581
physician who contracts to provide Services to Members
(but not including physicians who contract only to            • Los Angeles: 90001–84, 90086–91, 90093–96,
provide referral Services).                                     90101, 90103, 90189, 90201–02, 90209–13, 90220–
                                                                24, 90230–33, 90239–42, 90245, 90247–51, 90254–
Plan Provider: A Plan Hospital, a Plan Physician, the           55, 90260–67, 90270, 90272, 90274–75, 90277–78,
Medical Group, a Plan Pharmacy, or any other health             90280, 90290–96, 90301–12, 90401–11, 90501–10,
care provider that we designate as a Plan Provider.             90601–10, 90623, 90630–31, 90637–40, 90650–52,
Plan Skilled Nursing Facility: A Skilled Nursing                90660–62, 90670–71, 90701–03, 90706–07, 90710–
Facility approved by Health Plan.                               17, 90723, 90731–34, 90744–49, 90755, 90801–10,
                                                                90813–15, 90822, 90831–35, 90840, 90842, 90844,
Post-Stabilization Care: Medically Necessary Services           90846–48, 90853, 90895, 91001, 91003, 91006–12,
related to your Emergency Medical Condition that you            91016–17, 91020–21, 91023–25, 91030–31, 91040–
receive after your treating physician determines that this      43, 91046, 91066, 91077, 91101–10, 91114–18,
condition is Stabilized.                                        91121, 91123–26, 91129, 91182, 91184–85, 91188–
Premiums: Periodic membership charges paid by or on             89, 91199, 91201–10, 91214, 91221–22, 91224–26,
behalf of each Member. Premiums are in addition to any          91301–11, 91313, 91316, 91321–22, 91324–31,
Cost Sharing.                                                   91333–35, 91337, 91340–46, 91350–57, 91361–62,
                                                                91364–65, 91367, 91371–72, 91376, 91380–81,
Primary Care Physicians: Generalists in internal                91383–87, 91390, 91392–96, 91401–13, 91416,
medicine, pediatrics, and family practice, and specialists      91423, 91426, 91436, 91470, 91482, 91495–96,
in obstetrics/gynecology whom the Medical Group                 91499, 91501–08, 91510, 91521–23, 91601–12,
designates as Primary Care Physicians. Please refer to          91614–18, 91702, 91706, 91709, 91711, 91714–16,
our website at kp.org for a directory of Primary Care           91722–24, 91731–35, 91740–41, 91744–50, 91754–
Physicians, except that the directory is subject to change      56, 91765–73, 91775–76, 91778, 91780, 91788–93,
without notice. For the current list of physicians that are     91795, 91801–04, 91896, 93243, 93510, 93532,
available as Primary Care Physicians, please call the           93534–36, 93539, 93543–44, 93550–53, 93560,
personal physician selection department at the phone            93563, 93584, 93586, 93590–91, 93599
number listed in Your Guidebook.
                                                              • Riverside: 91752, 92201–03, 92210–11, 92220,
Rate Sheet: The document that lists premiums for the            92223, 92230, 92234–36, 92240–41, 92247–48,
"Kaiser Permanente Individual—Conversion Plan." The             92253–55, 92258, 92260–64, 92270, 92274, 92276,
Premium for your coverage under this Membership                 92282, 92292, 92320, 92324, 92373, 92399, 92501–
Agreement and Evidence of Coverage is listed in the             09, 92513–19, 92521–22, 92530–32, 92543–46,



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                       Page 6
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   92548, 92551–57, 92562–64, 92567, 92570–72,                          Coverage, the term "Spouse" includes the Subscriber's
   92581–87, 92589–93, 92595–96, 92599, 92860,                          same-sex spouse if the Subscriber and spouse are a
   92877–83                                                             couple who meet all of the requirements of Section
• San Bernardino: 91701, 91708–10, 91729–30, 91737,                     308(c) of the California Family Code, the Subscriber's
  91739, 91743, 91758–59, 91761–64, 91766, 91784–                       registered domestic partner who meets all of the
  86, 91792, 92252, 92256, 92268, 92277–78, 92284–                      requirements of Sections 297 or 299.2 of the California
  86, 92305, 92307–08, 92313–18, 92321–22, 92324–                       Family Code, or the Subscriber's domestic partner as
  26, 92329, 92331, 92333–37, 92339–41, 92344–46,                       determined by Health Plan.
  92350, 92352, 92354, 92357–59, 92369, 92371–78,                       Stabilize: To provide the medical treatment of the
  92382, 92385–86, 92391–95, 92397, 92399, 92401–                       Emergency Medical Condition that is necessary to
  08, 92410–15, 92418, 92423–24, 92427, 92880                           assure, within reasonable medical probability, that no
• San Diego: 91901–03, 91908–17, 91921, 91931–33,                       material deterioration of the condition is likely to result
  91935, 91941–47, 91950–51, 91962–63, 91976–80,                        from or occur during the transfer of the person from the
  91987, 92003, 92007–11, 92013–14, 92018–30,                           facility. With respect to a pregnant woman who is having
  92033, 92037–40, 92046, 92049, 92051–52, 92054–                       contractions, when there is inadequate time to safely
  61, 92064–65, 92067–69, 92071–72, 92074–75,                           transfer her to another hospital before delivery (or the
  92078–79, 92081–86, 92088, 92091–93, 92096,                           transfer may pose a threat to the health or safety of the
  92101–24, 92126–32, 92134–40, 92142–43, 92145,                        woman or unborn child), "Stabilize" means to deliver
  92147, 92149–50, 92152–55, 92158–79, 92182,                           (including the placenta).
  92184, 92186–87, 92190–99                                             Subscriber: A Member who is eligible for membership
• Ventura: 90265, 91304, 91307, 91311, 91319–20,                        on his or her own behalf and not by virtue of Dependent
  91358–62, 91377, 93001–07, 93009–12, 93015–16,                        status and for whom we have received applicable
  93020–22, 93030–36, 93040–44, 93060–66, 93094,                        Premiums.
  93099, 93252                                                          Urgent Care: Medically Necessary Services for a
For each ZIP code listed for a county, our Service Area                 condition that requires prompt medical attention but is
includes only the part of that ZIP code that is in that                 not an Emergency Medical Condition.
county. When a ZIP code spans more than one county,
the part of that ZIP code that is in another county is not
inside our Service Area, unless either (1) that other                  Premiums, Eligibility, and
county is entirely in our Service Area as listed above, or
(2) that other county is also listed above and that ZIP                Enrollment
code is also listed for that other county.
Note: We may expand our Service Area at any time by                    Premiums
giving written notice to the Subscriber. ZIP codes are
subject to change by the U.S. Postal Service.                           You must prepay the Premiums listed on the Rate Sheet,
                                                                        applicable to your coverage, for each month on or before
Services: Health care services or items ("health care"
                                                                        the last day of the preceding month. We may amend the
includes both physical health care and mental health
                                                                        Premiums listed on the Rate Sheet upon 30-days
care).
                                                                        prior written notice, as described under "Term and
Skilled Nursing Facility: A facility that provides                      amendment of this Membership Agreement and
inpatient skilled nursing care, rehabilitation services, or             Evidence of Coverage" in the "Introduction" section.
other related health services and is licensed by the state              Also, your Premiums may change as follows:
of California. The facility's primary business must be the              • When you move to a new rate area, any change in
provision of 24-hour-a-day licensed skilled nursing care.                 Premiums will take effect at the same time the change
The term "Skilled Nursing Facility" does not include                      in your coverage becomes effective
convalescent nursing homes, rest facilities, or facilities
for the aged, if those facilities furnish primarily custodial           • When the Subscriber progresses to a new age band,
care, including training in routines of daily living. A                   any change in Premiums will take effect upon
"Skilled Nursing Facility" may also be a unit or section                  renewal
within another facility (for example, a hospital) as long
as it continues to meet this definition.                                Only Members for whom we have received the
                                                                        appropriate Premiums are entitled to coverage under this
Spouse: The Subscriber's legal husband or wife. For the                 Membership Agreement and Evidence of Coverage, and
purposes of this Membership Agreement and Evidence of



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 7
then only for the period for which we have received          membership under this Southern California Region
payment.                                                     Membership Agreement and Evidence of Coverage:
                                                             • Regions outside California. If you move to the
If a government agency or other taxing authority imposes       service area of a Region outside California, you may
or increases a tax or other charge (other than a tax on or     be able to apply for membership in that Region by
measured by net income) upon Health Plan or Plan               contacting the member or customer service
Providers (or any of their activities), then upon 30-days      department there, but the plan, including coverage,
prior written notice we may increase Premiums to               premiums, and eligibility requirements, might not be
include your share of the new or increased tax or charge.      the same. For the purposes of this eligibility rule, the
Your share is determined by dividing the number of             service areas of the Regions outside California may
enrolled Members in your Family by the total number of         change on January 1 of each year and are currently
Members enrolled in our Southern California Region.            the District of Columbia and parts of Colorado,
                                                               Georgia, Hawaii, Idaho, Maryland, Ohio, Oregon,
                                                               Virginia, and Washington. For more information,
Who Is Eligible                                                please call our Member Service Call Center
To enroll and to continue enrollment, you must meet all      • Northern California Region's service area. If you
of the eligibility requirements described in this "Who Is      move to our Northern California Region's service
Eligible" section.                                             area, we will transfer your membership to the
                                                               individual plan in that Region that is most similar to
Eligibility for conversion                                     this plan. All terms and conditions in your application
The Subscriber and Dependents (except newborns, newly          for membership, including the Arbitration
adopted children, and children placed with you or your         Agreement, will continue to apply. We will provide
Spouse for adoption) must have been Members under              you with a Northern California Region membership
one of our Group plans at the time of enrollment.              agreement and evidence of coverage, the effective
                                                               date of coverage, and a Kaiser Permanente ID card
You may not convert to our Kaiser Permanente                   with a new medical record number on it. Please refer
Individual—Conversion Plan if any of the following is          to the Rate Sheet for the premiums that apply in the
true:                                                          Northern California Region. For more information,
                                                               please call our Member Service Call Center
• You continue to be eligible for coverage through your
  Group (but not counting COBRA, Cal-COBRA,
                                                             If you move anywhere else outside our Service Area
  USERRA, or State Continuation Coverage after
                                                             after enrollment, you can continue your membership as
  COBRA or Cal-COBRA coverage)
                                                             long as you meet all other eligibility requirements.
• Your membership ends because our Membership                However, you must receive covered Services from Plan
  Agreement and Evidence of Coverage with your               Providers inside our Service Area, except as described in
  Group terminates and it is replaced by another plan        the sections listed below for the following Services:
  within 15 days of the termination date
                                                             • Authorized referrals as described under "Getting a
• We terminated your membership under "Termination             Referral" in the "How to Obtain Services" section
  for Cause" in the "Termination of Membership"
                                                             • Emergency ambulance Services as described under
  section
                                                               "Ambulance Services" in the "Benefits and Cost
• You live in the service area of a Region outside             Sharing" section
  California, except otherwise-eligible Dependent
                                                             • Emergency Services, Post-Stabilization Care, and
  children of the Subscriber or of the Subscriber's
                                                               Out-of-Area Urgent Care as described in the
  Spouse are not ineligible to be covered Dependents
                                                               "Emergency Services and Urgent Care" section
  solely because they live in a Region outside
  California                                                 • Hospice care as described under "Hospice Care" in
                                                               the "Benefits and Cost Sharing" section
Service Area eligibility requirements
The "Definitions" section describes our Service Area and     Members with Medicare
how it may change.                                           This Membership Agreement and Evidence of Coverage
                                                             is not intended for most Medicare beneficiaries. If,
If you live in or move to the service area of another        during the term of this Membership Agreement and
Region after enrollment, you are not eligible for            Evidence of Coverage, you are (or become) eligible for
                                                             Medicare (please see "Medicare" in the "Definitions"



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 8
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
section for the meaning of "eligible for" Medicare) you                 cycle. If you do not send us the Premium payment by the
may enroll in Kaiser Permanente Senior Advantage if                     due date on the bill, you will not be enrolled in our
you are eligible to enroll in the plan and the plan is                  Kaiser Permanente Individual—Conversion Plan.
available to you.
                                                                        Changing your benefit plan
Capacity limit. You may be ineligible to enroll in Kaiser               If you choose the Deductible 30/1500 Plan, you cannot
Permanente Senior Advantage if that plan has reached a                  change to the Copayment 25 Plan later unless you
capacity limit that the Centers for Medicare & Medicaid                 request it within 30 days of your effective date of
Services has approved. This limitation does not apply if                coverage under the Deductible 30/1500 Plan. If you
you are currently a Health Plan Member in the Northern                  choose the Copayment 25 Plan, you can change to the
California or Southern California Region who is eligible                Deductible 30/1500 Plan at any time.
for Medicare (for example, when you turn age 65).
                                                                        Effective date of coverage
Medicare late enrollment penalties. If you become                       If we approve your enrollment application, coverage will
eligible for Medicare Part B and do not enroll, Medicare                begin on the date your Group coverage ends, without
may require you to pay a late enrollment penalty if you                 lapse.
later enroll in Medicare Part B. However, if you delay
enrollment in Part B because you or your husband or
wife are still working and have coverage through an
employer group health plan, you may not have to pay the                How to Obtain Services
penalty. Also, if you are (or become) eligible for
Medicare and go without creditable prescription drug                    As a Member, you are selecting our medical care
coverage (drug coverage that is at least as good as the                 program to provide your health care. You must receive
standard Medicare Part D prescription drug coverage) for                all covered care from Plan Providers inside our Service
a continuous period of 63 days or more, you may have to                 Area, except as described in the sections listed below for
pay a late enrollment penalty if you later sign up for                  the following Services:
Medicare prescription drug coverage. If you are (or                     • Authorized referrals as described under "Getting a
become) eligible for Medicare, we will send you a notice                  Referral" in this "How to Obtain Services" section
that tells you whether your drug coverage under this
Membership Agreement and Evidence of Coverage is                        • Emergency ambulance Services as described under
creditable prescription drug coverage at the times                        "Ambulance Services" in the "Benefits and Cost
required by the Centers for Medicare & Medicaid                           Sharing" section
Services and upon your request. For more information,                   • Emergency Services, Post-Stabilization Care, and
contact our Member Service Call Center.                                   Out-of-Area Urgent Care as described in the
                                                                          "Emergency Services and Urgent Care" section

How to Enroll                                                           • Hospice care as described under "Hospice Care" in
                                                                          the "Benefits and Cost Sharing" section
This plan does not include dependent coverage, so each
person in your family who is accepted for coverage must                 Our medical care program gives you access to all of the
enroll as a Subscriber under his or her own Membership                  covered Services you may need, such as routine care
Agreement and Evidence of Coverage.                                     with your own personal Plan Physician, hospital care,
                                                                        laboratory and pharmacy Services, Emergency Services,
We must receive your application within 63 days of the                  Urgent Care, and other benefits described in the
date of our termination letter, or your membership                      "Benefits and Cost Sharing" section.
termination date, whichever date is later. To request an
application, please call our Member Service Call Center.
                                                                       Routine Care
If we approve your enrollment application, we will send
                                                                        If you need the following Services, you should schedule
you billing information within 30 days after we receive
                                                                        an appointment:
your application. You will have 45 days to pay the bill.
Because your coverage under our Kaiser Permanente                       • Preventive care (Services that protect against disease,
Individual—Conversion Plan begins when your Group                         promote health, or detect disease at its earliest stages
coverage ends (including Group continuation coverage),                    before noticeable symptoms develop)
your first payment to us will include coverage from when                • Periodic follow-up care (regularly scheduled follow-
your Group coverage ended through our current billing                     up care, such as visits to monitor a chronic condition)


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 9
• Other care that is not Urgent Care                         are Primary Care Physicians (generalists in internal
                                                             medicine, pediatrics, or family practice, or specialists in
To make a non-urgent appointment, please refer to Your       obstetrics/gynecology whom the Medical Group
Guidebook for appointment telephone numbers, or go to        designates as Primary Care Physicians). Some specialists
our website at kp.org to request an appointment online.      who are not designated as Primary Care Physicians but
                                                             who also provide primary care may be available as
                                                             personal Plan Physicians. For example, some specialists
Urgent Care                                                  in internal medicine and obstetrics/gynecology who are
                                                             not designated as Primary Care Physicians may be
An Urgent Care need is one that requires prompt medical      available as personal Plan Physicians.
attention but is not an Emergency Medical Condition. If
you think you may need Urgent Care, call the                 To learn how to select a personal Plan Physician, please
appropriate appointment or advice telephone number at a      refer to Your Guidebook or call our Member Service Call
Plan Facility. Please refer to Your Guidebook for            Center. You can find a directory of our Plan Physicians
appointment and advice telephone numbers.                    on our website at kp.org. For the current list of
                                                             physicians that are available as Primary Care Physicians,
For information about Out-of-Area Urgent Care, please        please call the personal physician selection department at
refer to "Urgent Care" in the "Emergency Services and        the phone number listed in Your Guidebook. You can
Urgent Care" section.                                        change your personal Plan Physician for any reason.


Not Sure What Kind of Care You Need?                         Getting a Referral
Sometimes it's difficult to know what kind of care you       Referrals to Plan Providers
need, so we have licensed health care professionals          A Plan Physician must refer you before you can receive
available to assist you by phone 24 hours a day, seven       care from specialists, such as specialists in surgery,
days a week. Here are some of the ways they can help         orthopedics, cardiology, oncology, urology,
you:                                                         dermatology, and physical, occupational, and speech
• They can answer questions about a health concern,          therapies. However, you do not need a referral or prior
  and instruct you on self-care at home if appropriate       authorization to receive care from any of the following:
• They can advise you about whether you should get           • Your personal Plan Physician
  medical care, and how and where to get care (for           • Generalists in internal medicine, pediatrics, and
  example, if you are not sure whether your condition is       family practice
  an Emergency Medical Condition, they can help you
  decide whether you need Emergency Services or              • Specialists in optometry, psychiatry, chemical
  Urgent Care, and how and where to get that care)             dependency, and obstetrics/gynecology
• They can tell you what to do if you need care and a
                                                             Although a referral or prior authorization is not required
  Plan Medical Office is closed
                                                             to receive care from these providers, the provider may
                                                             have to get prior authorization for certain Services in
You can reach one of these licensed health care              accord with "Medical Group authorization procedure for
professionals by calling the appointment or advice           certain referrals" in this "Getting a Referral" section.
telephone number listed in Your Guidebook. When you
call, a trained support person may ask you questions to      Medical Group authorization procedure for
help determine how to direct your call.                      certain referrals
                                                             The following Services require prior authorization by the
Your Personal Plan Physician                                 Medical Group for the Services to be covered ("prior
                                                             authorization" means that the Medical Group must
Personal Plan Physicians provide primary care and play       approve the Services in advance):
an important role in coordinating care, including hospital   • Durable medical equipment. If your Plan Physician
stays and referrals to specialists.                            prescribes durable medical equipment, he or she will
                                                               submit a written referral to the Plan Hospital's durable
We encourage you to choose a personal Plan Physician.          medical equipment coordinator, who will authorize
You may choose any available personal Plan Physician.          the durable medical equipment if he or she
Parents may choose a pediatrician as the personal Plan         determines that your durable medical equipment
Physician for their child. Most personal Plan Physicians


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 10
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   coverage includes the item and that the item is listed                  Plan Physician may provide or authorize a corneal
   on our formulary for your condition. If the item                        transplant without using this Medical Group
   doesn't appear to meet our durable medical equipment                    transplant authorization procedure
   formulary guidelines, then the durable medical
   equipment coordinator will contact the Plan Physician                Decisions regarding requests for authorization will be
   for additional information. If the durable medical                   made only by licensed physicians or other appropriately
   equipment request still doesn't appear to meet our                   licensed medical professionals.
   durable medical equipment formulary guidelines, it
   will be submitted to the Medical Group's designee                    Medical Group's decision time frames. The applicable
   Plan Physician, who will authorize the item if he or                 Medical Group designee will make the authorization
   she determines that it is Medically Necessary. For                   decision within the time frame appropriate for your
   more information about our durable medical                           condition, but no later than five business days after
   equipment formulary, please refer to "Durable                        receiving all the information (including additional
   Medical Equipment for Home Use" in the "Benefits                     examination and test results) reasonably necessary to
   and Cost Sharing" section                                            make the decision, except that decisions about urgent
• Ostomy and urological supplies. If your Plan                          Services will be made no later than 72 hours after receipt
  Physician prescribes ostomy or urological supplies,                   of the information reasonably necessary to make the
  he or she will submit a written referral to the Plan                  decision. If the Medical Group needs more time to make
  Hospital's designated coordinator, who will authorize                 the decision because it doesn't have information
  the item if he or she determines that it is covered and               reasonably necessary to make the decision, or because it
  the item is listed on our soft goods formulary for your               has requested consultation by a particular specialist, you
  condition. If the item doesn't appear to meet our soft                and your treating physician will be informed about the
  goods formulary guidelines, then the coordinator will                 additional information, testing, or specialist that is
  contact the Plan Physician for additional information.                needed, and the date that the Medical Group expects to
  If the request still doesn't appear to meet our soft                  make a decision.
  goods formulary guidelines, it will be submitted to
  the Medical Group's designee Plan Physician, who                      Your treating physician will be informed of the decision
  will authorize the item if he or she determines that it               within 24 hours after the decision is made. If the Services
  is Medically Necessary. For more information about                    are authorized, your physician will be informed of the
  our soft goods formulary, please refer to "Ostomy and                 scope of the authorized Services. If the Medical Group
  Urological Supplies" in the "Benefits and Cost                        does not authorize all of the Services, Health Plan will
  Sharing" section                                                      send you a written decision and explanation within two
                                                                        business days after the decision is made. The letter will
• Services not available from Plan Providers. If your
                                                                        include information about your appeal rights, which are
  Plan Physician decides that you require covered
                                                                        described in the "Dispute Resolution" section. Any
  Services not available from Plan Providers, he or she
                                                                        written criteria that the Medical Group uses to make the
  will recommend to the Medical Group that you be
                                                                        decision to authorize, modify, delay, or deny the request
  referred to a Non–Plan Provider inside or outside our
                                                                        for authorization will be made available to you upon
  Service Area. The appropriate Medical Group
                                                                        request.
  designee will authorize the Services if he or she
  determines that they are Medically Necessary and are
                                                                        Cost Sharing. The Cost Sharing for these referral
  not available from a Plan Provider. Referrals to Non–
                                                                        Services is the Cost Sharing required for Services
  Plan Physicians will be for a specific treatment plan,
                                                                        provided by a Plan Provider as described in the "Benefits
  which may include a standing referral if ongoing care
                                                                        and Cost Sharing" section.
  is prescribed. Please ask your Plan Physician what
  Services have been authorized
                                                                        More information. This description is only a brief
• Transplants. If your Plan Physician makes a written                   summary of the authorization procedure. The policies
  referral for a transplant, the Medical Group's regional               and procedures (including a description of the
  transplant advisory committee or board (if one exists)                authorization procedure or information about the
  will authorize the Services if it determines that they                authorization procedure applicable to some Plan
  are Medically Necessary. In cases where no                            Providers other than Kaiser Foundation Hospitals and the
  transplant committee or board exists, the Medical                     Medical Group) are available upon request from our
  Group will refer you to physician(s) at a transplant                  Member Service Call Center. Please refer to "Post-
  center, and the Medical Group will authorize the                      Stabilization Care" under "Emergency Services" in the
  Services if the transplant center's physician(s)                      "Emergency Services and Urgent Care" section for
  determine that they are Medically Necessary. Note: A


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 11
authorization requirements that apply to Post-                medical and hospital care for Members, please ask your
Stabilization Care from Non–Plan Providers.                   Plan Physician or call our Member Service Call Center.

                                                              Financial liability
Second Opinions                                               Our contracts with Plan Providers provide that you are
                                                              not liable for any amounts we owe. However, you may
If you request a second opinion, it will be provided to
                                                              be liable for the full price of noncovered Services you
you when Medically Necessary by an appropriately
                                                              obtain from Plan Providers or Non–Plan Providers.
qualified medical professional. This is a physician who is
acting within his or her scope of practice and who
                                                              Breach of contract
possesses a clinical background related to the illness or
condition associated with the request for a second            We will give you written notice within a reasonable time
medical opinion. Here are some examples of when a             if any contracted provider breaches a contract with us, or
second opinion is Medically Necessary:                        is not able to provide contracted Services, if you might
                                                              be materially and adversely affected.
• Your Plan Physician has recommended a procedure
  and you are unsure about whether the procedure is           Termination of a Plan Provider's contract and
  reasonable or necessary                                     completion of Services
• You question a diagnosis or plan of care for a              If our contract with any Plan Provider terminates while
  condition that threatens substantial impairment or loss     you are under the care of that provider, we will retain
  of life, limb, or bodily functions                          financial responsibility for covered care you receive from
• The clinical indications are not clear or are complex       that provider until we make arrangements for the
  and confusing                                               Services to be provided by another Plan Provider and
                                                              notify you of the arrangements. We will give you 60
• A diagnosis is in doubt due to conflicting test results     days prior written notice (or as soon as reasonably
• The Plan Physician is unable to diagnose the                possible) if a contracted provider group or hospital
  condition                                                   terminates a contract with us and you might be materially
                                                              and adversely affected.
• The treatment plan in progress is not improving your
  medical condition within an appropriate period of
  time, given the diagnosis and plan of care                  In addition, if you are currently receiving covered
                                                              Services in one of the following cases from a Plan
• You have concerns about the diagnosis or plan of care       Hospital or a Plan Physician (or certain other providers)
                                                              when our contract with the provider ends (for reasons
You can either ask your Plan Physician to help you            other than medical disciplinary cause or criminal
arrange for a second medical opinion, or you can make         activity), you may be eligible for limited coverage of that
an appointment with another Plan Physician. If the            terminated provider's Services:
Medical Group determines that there isn't a Plan
                                                              • Acute conditions, which are medical conditions that
Physician who is an appropriately qualified medical
                                                                involve a sudden onset of symptoms due to an illness,
professional for your condition, the Medical Group will
                                                                injury, or other medical problem that requires prompt
authorize a referral to a Non–Plan Physician for a
                                                                medical attention and has a limited duration. We may
Medically Necessary second opinion.
                                                                cover these Services until the acute condition ends
Cost Sharing. The Cost Sharing for these referral             • We may cover Services for serious chronic conditions
Services is the Cost Sharing required for Services              until the earlier of (1) 12 months from the termination
provided by a Plan Provider as described in the "Benefits       date of the terminated provider, or (2) the first day
and Cost Sharing" section.                                      after a course of treatment is complete when it would
                                                                be safe to transfer your care to a Plan Provider, as
                                                                determined by Kaiser Permanente after consultation
Contracts with Plan Providers                                   with the Member and Non–Plan Provider and
                                                                consistent with good professional practice. Serious
How Plan Providers are paid                                     chronic conditions are illnesses or other medical
Health Plan and Plan Providers are independent                  conditions that are serious, if one of the following is
contractors. Plan Providers are paid in a number of ways,       true about the condition:
such as salary, capitation, per diem rates, case rates, fee     ♦ it persists without full cure
for service, and incentive payments. To learn more about
how Plan Physicians are paid to provide or arrange               ♦ it worsens over an extended period of time




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                       Page 12
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   ♦ it requires ongoing treatment to maintain                          area. Visiting member care is described in our visiting
       remission or prevent deterioration                               member brochure. Visiting member care and your out-
• Pregnancy and immediate postpartum care. We may                       of-pocket costs may differ from the covered Services and
  cover these Services for the duration of the pregnancy                Cost Sharing described in this Membership Agreement
  and immediate postpartum care                                         and Evidence of Coverage.

• Terminal illnesses, which are incurable or irreversible               The 90-day limit on visiting member care does not apply
  illnesses that have a high probability of causing death               to a Dependent child who attends an accredited college
  within a year or less. We may cover completion of                     or accredited vocational school. The service areas and
  these Services for the duration of the illness                        facilities where you may obtain visiting member care
• Care for children under age 3. We may cover                           may change at any time without notice.
  completion of these Services until the earlier of (1) 12
  months from the termination date of the terminated                    Please call our Member Service Call Center for more
  provider, or (2) the child's third birthday                           information about visiting member care, including
• Surgery or another procedure that is documented as                    facility locations in the service area of another Region,
  part of a course of treatment and has been                            and to request a copy of the visiting member brochure.
  recommended and documented by the provider to
  occur within 180 days of the termination date of the
                                                                       Your ID Card
  terminated provider
                                                                        Each Member's Kaiser Permanente ID card has a medical
To qualify for this completion of Services coverage, all                record number on it, which you will need when you call
of the following requirements must be met:                              for advice, make an appointment, or go to a provider for
• Your Health Plan coverage is in effect on the date                    covered care. When you get care, please bring your
  you receive the Service                                               Kaiser Permanente ID card and a photo ID. Your
                                                                        medical record number is used to identify your medical
• You are receiving Services in one of the cases listed                 records and membership information. Your medical
  above from the terminated Plan Provider on the                        record number should never change. Please call our
  provider's termination date                                           Member Service Call Center if we ever inadvertently
• The provider agrees to our standard contractual terms                 issue you more than one medical record number or if you
  and conditions, such as conditions pertaining to                      need to replace your Kaiser Permanente ID card.
  payment and to providing Services inside our Service
  Area                                                                  Your ID card is for identification only. To receive
• The Services to be provided to you would be covered                   covered Services, you must be a current Member.
  Services under this Membership Agreement and                          Anyone who is not a Member will be billed as a non-
  Evidence of Coverage if provided by a Plan Provider                   Member for any Services he or she receives. If you let
                                                                        someone else use your ID card, we may keep your ID
• You request completion of Services within 30 days                     card and terminate your membership as described under
  (or as soon as reasonably possible) from the                          "Termination for Cause" in the "Termination of
  termination date of the Plan Provider                                 Membership" section.

Cost Sharing. The Cost Sharing for completion of
Services is the Cost Sharing required for Services                     Getting Assistance
provided by a Plan Provider as described in the "Benefits
and Cost Sharing" section.                                              We want you to be satisfied with the health care you
                                                                        receive from Kaiser Permanente. If you have any
More information. For more information about this                       questions or concerns, please discuss them with your
provision, or to request the Services or a copy of our                  personal Plan Physician or with other Plan Providers
"Completion of Covered Services" policy, please call our                who are treating you. They are committed to your
Member Service Call Center.                                             satisfaction and want to help you with your questions.

                                                                        Member Services
Visiting Other Regions                                                  Most Plan Facilities have an office staffed with
                                                                        representatives who can provide assistance if you need
If you visit the service area of another Region                         help obtaining Services. At different locations, these
temporarily (not more than 90 days), you can receive                    offices may be called Member Services, Patient
visiting member care from designated providers in that


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 13
Assistance, or Customer Service. In addition, our             Plan Hospitals and Plan Medical Offices
Member Service Call Center representatives are
available to assist you weekdays from 7 a.m. to 7 p.m.        The following is a list of Plan Hospitals and most Plan
and weekends from 7 a.m. to 3 p.m. (except holidays)          Medical Offices in our Service Area. Please refer to Your
toll free at 1-800-464-4000 or 1-800-777-1370 (TTY for        Guidebook for the types of covered Services that are
the deaf, hard of hearing, or speech impaired). For your      available from each Plan Facility in your area, because
convenience, you can also contact us through our website      some facilities provide only specific types of covered
at kp.org.                                                    Services. Additional Plan Medical Offices are listed in
                                                              Your Guidebook and on our website at kp.org. This list
Member Services representatives at our Plan Facilities        is subject to change at any time without notice. If you
and Member Service Call Center can answer any                 have any questions about the current locations of Plan
questions you have about your benefits, available             Facilities, please call our Member Service Call Center.
Services, and the facilities where you can receive care.      Aliso Viejo
For example, they can explain your Health Plan benefits,
how to make your first medical appointment, what to do        • Medical Offices: 24502 Pacific Park Dr.
if you move, what to do if you need care while you are        Anaheim
traveling, and how to replace your ID card. These
representatives can also help you if you need to file a       • Hospital and Medical Offices: 441 N. Lakeview Ave.
claim as described in the "Emergency Services and             • Medical Offices: 411 N. Lakeview Ave., 5475 E.
Urgent Care" section or with any issues as described in         La Palma Ave., and 1188 N. Euclid St.
the "Dispute Resolution" section.
                                                              Bakersfield
Interpreter services                                          • Hospital: 2615 Chester Ave.
If you need interpreter services when you call us or when       (San Joaquin Community Hospital)
you get covered Services, please let us know. Interpreter     • Medical Offices: 1200 Discovery Dr.,
services are available 24 hours a day, seven days a week,       3501 Stockdale Hwy., 3700 Mall View Rd.,
at no cost to you. For more information on the interpreter      4801 Coffee Rd., and 8800 Ming Ave.
services we offer, please call our Member Service Call
Center.                                                       Baldwin Park
                                                              • Hospital and Medical Offices: 1011 Baldwin Park
                                                                Blvd.
Plan Facilities                                               Bellflower
                                                              • Medical Offices: 9400 E. Rosecrans Ave.
At most of our Plan Facilities, you can usually receive all
of the covered Services you need, including specialty         Bonita
care, pharmacy, and lab work. You are not restricted to a     • Medical Offices: 3955 Bonita Rd.
particular Plan Facility, and we encourage you to use the
                                                              Brea
facility that will be most convenient for you:
                                                              • Medical Offices: 1900 E. Lambert Rd.
• All Plan Hospitals provide inpatient Services and are
  open 24 hours a day, seven days a week                      Camarillo
• Emergency Services are available from Plan Hospital         • Medical Offices: 2620 E. Las Posas Rd.
  Emergency Departments as described in Your
                                                              Carlsbad
  Guidebook (please refer to Your Guidebook for
  Emergency Department locations in your area)                • Medical Offices: 6860 Avenida Encinas
• Same-day Urgent Care appointments are available at          Chino
  many locations (please refer to Your Guidebook for          • Medical Offices: 11911 Central Ave.
  Urgent Care locations in your area)
                                                              Claremont
• Many Plan Medical Offices have evening and
  weekend appointments                                        • Medical Offices: 250 W. San Jose St.
• Many Plan Facilities have a Member Services                 Colton
  Department (refer to Your Guidebook for locations in        • Medical Offices: 789 S. Cooley Dr.
  your area)




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 14
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Corona                                                                  Joshua Tree
• Medical Offices: 2055 Kellogg Ave.                                    • Hospital: 6601 White Feather Rd. (Hi-
                                                                          Desert Medical Center)
Cudahy
                                                                        • Please refer to Your Guidebook for other Plan
• Medical Offices: 7825 Atlantic Ave.
                                                                          Providers in the Yucca Valley–Twentynine Palms
Culver City                                                               area
• Medical Offices: 5620 Mesmer Ave.                                     La Mesa
Diamond Bar                                                             • Medical Offices: 8080 Parkway Dr. and
• Medical Offices: 1336 Bridge Gate Dr.                                   3875 Avocado Blvd.

Downey                                                                  La Palma

• Hospital: 9333 E. Imperial Hwy.                                       • Medical Offices: 5 Centerpointe Dr.

• Medical Offices: 9449 E. Imperial Hwy.                                Lancaster

El Cajon                                                                • Hospitals: 1600 W. Avenue J
                                                                          (Antelope Valley Hospital) and 43830 N. 10th St. W.
• Medical Offices: 1630 E. Main St.                                       (Lancaster Community Hospital)*
Escondido                                                                  * This hospital is expected to close in 2011 (upon
• Hospital: 555 E. Valley Pkwy.                                              closure of this facility, it will no longer be a Plan
                                                                             Hospital)
  (Palomar Medical Center)
• Medical Offices: 732 N. Broadway St.                                  • Medical Offices: 43112 N. 15th St. W.
Fontana                                                                 Long Beach
• Hospital and Medical Offices: 9961 Sierra Ave.                        • Medical Offices: 3900 E. Pacific Coast Hwy.
Garden Grove                                                            Los Angeles
• Medical Offices: 12100 Euclid St.                                     • Hospitals and Medical Offices: 1526 N. Edgemont St.
                                                                          and 6041 Cadillac Ave.
Gardena
                                                                        • Medical Offices: 5119 E. Pomona Blvd. and
• Medical Offices: 15446 S. Western Ave.                                  12001 W. Washington Blvd.
Glendale                                                                Lynwood
• Medical Offices: 444 W. Glenoaks Blvd.                                • Medical Offices: 3840 Martin Luther King Jr. Blvd.
Harbor City                                                             Mission Hills
• Hospital and Medical Offices: 25825 S. Vermont                        • Medical Offices: 11001 Sepulveda Blvd.
  Ave.
                                                                        Mission Viejo
Huntington Beach
                                                                        • Medical Offices: 23781 Maquina Ave.
• Medical Offices: 18081 Beach Blvd.
                                                                        Montebello
Indio
                                                                        • Medical Offices: 1550 Town Center Dr.
• Hospital: 47111 Monroe St. (John F.
  Kennedy Memorial Hospital)                                            Moreno Valley
• Medical Offices: 81-719 Doctor Carreon Blvd.                          • Hospital: 27300 Iris Ave.
                                                                          (Moreno Valley Community Hospital)
Inglewood
                                                                        • Medical Offices: 12815 Heacock St.
• Medical Offices: 110 N. La Brea Ave.
                                                                        Murrieta
Irvine
                                                                        • Hospital: 25500 Medical Center Dr.
• Hospital and Medical Offices: 6640 Alton Pkwy.                          (Rancho Springs Medical Center)
• Medical Offices: 6 Willard St.
                                                                        Oceanside
                                                                        • Medical Offices: 3609 Ocean Ranch Blvd.


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 15
Ontario                                                     Simi Valley
• Medical Offices: 2295 S. Vineyard Ave.                    • Medical Offices: 3900 Alamo St.
Oxnard                                                      Temecula
• Medical Offices: 2200 E. Gonzales Rd.                     • Medical Offices: 27309 Madison Ave.
Palm Desert                                                 Thousand Oaks
• Medical Offices: 75-036 Gerald Ford Dr.                   • Medical Offices: 365 E. Hillcrest Dr. and
                                                              145 Hodencamp Rd.
Palm Springs
• Hospital: 1150 N. Indian Canyon Dr.                       Torrance
  (Desert Regional Medical Center)                          • Medical Offices: 20790 Madrona Ave.
• Medical Offices: 1100 N. Palm Canyon Dr.                  Upland
Palmdale                                                    • Medical Offices: 1183 E. Foothill Blvd.
• Medical Offices: 4502 E. Avenue S                         Ventura
Panorama City                                               • Hospital: 147 N. Brent St. (Community Memorial
• Hospital and Medical Offices: 13652 Cantara St.             Hospital of San Buenaventura)
                                                            • Medical Offices: 888 S. Hill Rd.
Pasadena
• Medical Offices: 3280 E. Foothill Blvd.                   Victorville
                                                            • Medical Offices: 14011 Park Ave.
Rancho Cucamonga
• Medical Offices: 10850 Arrow Rte.                         West Covina
                                                            • Medical Offices: 1249 Sunset Ave.
Redlands
• Medical Offices: 1301 California St.                      Whittier
                                                            • Medical Offices: 12470 Whittier Blvd.
Riverside
• Hospital and Medical Offices: 10800 Magnolia Ave.         Wildomar
                                                            • Hospital: 36485 Inland Valley Dr.
San Bernardino
                                                              (Inland Valley Medical Center)
• Medical Offices: 1717 Date Pl.
                                                            • Medical Offices: 36450 Inland Valley Dr.
San Diego
                                                            Woodland Hills
• Hospital and Medical Offices: 4647 Zion Ave.
                                                            • Hospital and Medical Offices: 5601 De Soto Ave.
• Medical Offices: 3250 Wing St., 4405 Vandever
                                                            • Medical Offices: 21263 Erwin St.
  Ave., 4650 Palm Ave., 7060 Clairemont Mesa Blvd.,
  and 11939 Rancho Bernardo Rd.                             Yorba Linda
San Dimas                                                   • Medical Offices: 22550 E. Savi Ranch Pkwy.
• Medical Offices: 1255 W. Arrow Hwy.
                                                            Note: State law requires evidence of coverage documents
San Juan Capistrano                                         to include the following notice: "Some hospitals and
• Medical Offices: 30400 Camino Capistrano                  other providers do not provide one or more of the
                                                            following services that may be covered under your plan
San Marcos                                                  contract and that you or your family member might need:
• Medical Offices: 400 Craven Rd.                           family planning; contraceptive services, including
                                                            emergency contraception; sterilization, including tubal
Santa Ana                                                   ligation at the time of labor and delivery; infertility
• Medical Offices: 3401 S. Harbor Blvd. and 1900 E.         treatments; or abortion. You should obtain more
  4th St.                                                   information before you enroll. Call your prospective
                                                            doctor, medical group, independent practice association,
Santa Clarita
                                                            or clinic, or call the Kaiser Permanente Member Service
• Medical Offices: 27107 Tourney Rd.



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                  Page 16
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
Call Center, to ensure that you can obtain the health care              condition is Stabilized. We cover Post-Stabilization Care
services that you need."                                                from a Non–Plan Provider, including inpatient care at a
                                                                        Non–Plan Hospital, only if we provide prior
Please be aware that if a Service is covered but not                    authorization for the care or if otherwise required by
available at a particular Plan Facility, we will make it                applicable law ("prior authorization" means that we must
available to you at another facility.                                   approve the Services in advance).

                                                                        To request authorization to receive Post-Stabilization
Your Guidebook to Kaiser Permanente                                     Care from a Non–Plan Provider, you must call us toll
Services (Your Guidebook)                                               free at 1-800-225-8883 (TTY users call 711) or the
                                                                        notification telephone number on your Kaiser
Plan Medical Offices and Plan Hospitals for your area                   Permanente ID card before you receive the care if it is
are listed in greater detail in Your Guidebook to Kaiser                reasonably possible to do so (otherwise, call us as soon
Permanente Services (Your Guidebook). Your Guidebook                    as reasonably possible). After we are notified, we will
describes the types of covered Services that are available              discuss your condition with the Non–Plan Provider. If we
from each Plan Facility in your area, because some                      decide that you require Post-Stabilization Care and that
facilities provide only specific types of covered Services.             this care would be covered if you received it from a Plan
It includes additional facilities that are not listed in this           Provider, we will authorize your care from the Non–Plan
"Plan Facilities" section. Also, it explains how to use our             Provider or arrange to have a Plan Provider (or other
Services and make appointments, lists hours of                          designated provider) provide the care. If we decide to
operation, and includes a detailed telephone directory for              have a Plan Hospital, Plan Skilled Nursing Facility, or
appointments and advice. Your Guidebook provides other                  designated Non–Plan Provider provide your care, we
important information, such as preventive care guidelines               may authorize special transportation services that are
and your Member rights and responsibilities. Your                       medically required to get you to the provider. This may
Guidebook is subject to change and is periodically                      include transportation that is otherwise not covered.
updated. You can get a copy by visiting our website at
kp.org or by calling our Member Service Call Center.                    Be sure to ask the Non–Plan Provider to tell you what
                                                                        care (including any transportation) we have authorized
                                                                        because we will not cover unauthorized Post-
Emergency Services and Urgent                                           Stabilization Care or related transportation provided by
                                                                        Non–Plan Providers.
Care
                                                                        We understand that extraordinary circumstances can
                                                                        delay your ability to call us to request authorization for
Emergency Services                                                      Post-Stabilization Care from a Non–Plan Provider, for
If you have an Emergency Medical Condition, call 911                    example, if a young child is without a parent or guardian
(where available) or go to the nearest hospital                         present, or you are unconscious. In these cases, you must
Emergency Department. You do not need prior                             call us as soon as reasonably possible. Please keep in
authorization for Emergency Services. When you have                     mind that anyone can call us for you. We do not cover
an Emergency Medical Condition, we cover Emergency                      any care you receive from Non–Plan Providers after your
Services you receive from Plan Providers or Non–Plan                    Emergency Medical Condition is Stabilized unless we
Providers anywhere in the world as long as the Services                 authorize it, so if you don't call as soon as reasonably
would have been covered under the "Benefits and Cost                    possible, you increase the risk that you will have to pay
Sharing" section (subject to the "Exclusions, Limitations,              for this care.
Coordination of Benefits, and Reductions" section) if
you had received them from Plan Providers.                              Cost Sharing
                                                                        The Cost Sharing for covered Emergency Services and
Emergency Services are available from Plan Hospital                     Post-Stabilization Care is the Cost Sharing required for
Emergency Departments 24 hours a day, seven days a                      Services provided by Plan Providers as described in the
week.                                                                   "Benefits and Cost Sharing" section:
                                                                        • Please refer to "Outpatient Care" for the Cost Sharing
Post-Stabilization Care                                                   for Emergency Department visits
Post-Stabilization Care is Medically Necessary Services
                                                                        • The Cost Sharing for other covered Emergency
related to your Emergency Medical Condition that you
                                                                          Services and Post-Stabilization Care is the Cost
receive after your treating physician determines that this
                                                                          Sharing that you would pay if the Services were not


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 17
   Emergency Services or Post-Stabilization Care. For        Cost Sharing
   example, if you are admitted as an inpatient to a Non–    The Cost Sharing for covered Urgent Care is the Cost
   Plan Hospital for Post-Stabilization Care and we give     Sharing required for Services provided by Plan Providers
   prior authorization for that care, your Cost Sharing      as described in the "Benefits and Cost Sharing" section:
   would be the Cost Sharing listed under "Hospital
                                                             • Please refer to "Outpatient Care" for the Cost Sharing
   Inpatient Care"
                                                               for Urgent Care consultations and exams
Services not covered under this "Emergency                   • The Cost Sharing for other covered Urgent Care is the
Services" section                                              Cost Sharing that you would pay if the Services were
Coverage for the following Services is described in other      not Urgent Care. For example, if the Urgent Care you
sections of this Membership Agreement and Evidence of          receive includes an X-ray, your Cost Sharing for the
Coverage:                                                      X-ray would be the Cost Sharing for an X-ray listed
                                                               under "Outpatient Imaging, Laboratory, and Special
• Follow-up care and other Services that are not               Procedures"
  Emergency Services or Post-Stabilization Care
  described in this "Emergency Services" section (refer      Services not covered under this "Urgent Care"
  to the "Benefits and Cost Sharing" section for             section
  coverage, subject to the "Exclusions, Limitations,
                                                             Coverage for the following Services is described in other
  Coordination of Benefits, and Reductions" section)
                                                             sections of this Membership Agreement and Evidence of
• Out-of-Area Urgent Care (refer to "Out-of-Area             Coverage:
  Urgent" care under "Urgent Care" in this "Emergency
                                                             • Follow-up care and other Services that are not Urgent
  Services and Urgent Care" section)
                                                               Care or Out-of-Area Urgent Care described in this
                                                               "Urgent Care" section (refer to the "Benefits and Cost
Urgent Care                                                    Sharing" section for coverage, subject to the
                                                               "Exclusions, Limitations, Coordination of Benefits,
Inside the Service Area                                        and Reductions" section)
An Urgent Care need is one that requires prompt medical
attention but is not an Emergency Medical Condition. If
you think you may need Urgent Care, call the                 Payment and Reimbursement
appropriate appointment or advice telephone number at a
                                                             If you receive Emergency Services, Post-Stabilization
Plan Facility. Please refer to Your Guidebook for
                                                             Care, or Out-of-Area Urgent Care from a Non–Plan
appointment and advice telephone numbers.
                                                             Provider as described in this "Emergency Services and
                                                             Urgent Care" section, or emergency ambulance Services
Out-of-Area Urgent Care
                                                             described under "Ambulance Services" in the "Benefits
If you have an Urgent Care need due to an unforeseen         and Cost Sharing" section, you must pay the provider
illness, unforeseen injury, or unforeseen complication of    and file a claim for reimbursement unless the provider
an existing condition (including pregnancy), we cover        agrees to bill us. Also, you may be required to pay and
Medically Necessary Services to prevent serious              file a claim for any Services prescribed by a Non–Plan
deterioration of your (or your unborn child's) health from   Provider as part of covered Emergency Services, Post-
a Non–Plan Provider if all of the following are true:        Stabilization Care, and Out-of-Area Urgent Care even if
• You receive the Services from Non–Plan Providers           you receive the Services from a Plan Provider, such as a
  while you are temporarily outside our Service Area         Plan Pharmacy.
• You reasonably believed that your (or your unborn
  child's) health would seriously deteriorate if you         We will reduce any payment we make to you or the
  delayed treatment until you returned to our Service        Non–Plan Provider by applicable Cost Sharing. Also, we
  Area                                                       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 any insurance policy, or
You do not need prior authorization for Out-of-Area
                                                             any other contract or coverage, or any government
Urgent Care. We cover Out-of-Area Urgent Care you
                                                             program except Medicaid. If payment under the other
receive from Non–Plan Providers as long as the Services
                                                             insurance or program is not made within a reasonable
would have been covered under the "Benefits and Cost
                                                             period of time, we will pay for covered Emergency
Sharing" section (subject to the "Exclusions, Limitations,
                                                             Services, Post-Stabilization Care, and Out-of-Area
Coordination of Benefits, and Reductions" section) if
                                                             Urgent Care received from Non–Plan Providers if you:
you had received them from Plan Providers.



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 18
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Assign all rights to payment to us and agree to                       after the date we receive the additional information. If
  cooperate with us in obtaining payment                                we do not receive the necessary information within the
                                                                        timeframe specified in the letter, we will make our
• Allow us to obtain any relevant information from the
                                                                        decision based on the information we have. If our
  other insurance or program
                                                                        decision is not fully in your favor, we will tell you the
• Provide us with any information and assistance we                     reasons and how to file a grievance as described under
  need to obtain payment from the other insurance or                    "Grievances" in the "Dispute Resolution" section.
  program

How to file a claim
To file a claim for payment or reimbursement, this is
                                                                       Benefits and Cost Sharing
what you need to do:
                                                                        We cover the Services described in this "Benefits and
• As soon as possible, send us a completed claim form.                  Cost Sharing" section, subject to the "Exclusions,
  You can get a claim form by visiting our website at                   Limitations, Coordination of Benefits, and Reductions"
  kp.org or by calling our Member Service Call Center                   section, only if all of the following conditions are
  toll free at 1-800-464-4000 or 1-800-390-3510 (TTY                    satisfied:
  users call 1-800-777-1370). One of our
  representatives will be happy to assist you if you need               • You are a Member on the date that you receive the
  help completing our claim form                                          Services

• If you have paid for Services, you must include any                   • The Services are Medically Necessary
  bills and receipts from the Non–Plan Provider with                    • The Services are one of the following:
  your claim form                                                          ♦ health care items and services for preventive care
• To request that we pay a Non–Plan Provider for                           ♦ health care items and services for diagnosis,
  Services, you must include any bills from the Non–                           assessment, or treatment
  Plan Provider with your claim form. If the Non–Plan
                                                                           ♦ health education covered under "Health
  Provider states that they will submit the claim, you
                                                                               Education" in this "Benefits and Cost Sharing"
  are still responsible for making sure that we receive
                                                                               section
  everything we need to process the request for
  payment. If you later receive any bills from the Non–                    ♦ other health care items and services
  Plan Provider for covered Services (other than bills                  • The Services are provided, prescribed, authorized, or
  for your Cost Sharing amount), please call our                          directed by a Plan Physician except where
  Member Service Call Center toll free at                                 specifically noted to the contrary in the sections listed
  1-800-390-3510 for assistance                                           below for the following Services:
• The completed claim form and any bills or receipts                       ♦ emergency ambulance Services as described under
  must be mailed to the following address as soon as                           "Ambulance Services" in this "Benefits and Cost
  possible after receiving the care:                                           Sharing" section
   Kaiser Foundation Health Plan, Inc.                                     ♦ Emergency Services, Post-Stabilization Care, and
   Claims Department                                                           Out-of-Area Urgent Care as described in the
   P.O. Box 7004                                                               "Emergency Services and Urgent Care" section
   Downey, CA 90242-7004
                                                                        • You receive the Services from Plan Providers inside
                                                                          our Service Area, except where specifically noted to
If we ask you to provide information or complete a                        the contrary in the sections listed below for the
document in connection with your claim, you must send                     following Services:
it to our Claims Department at the address above. For
                                                                           ♦ authorized referrals as described under "Getting a
example, we might request that you provide completed
claim forms, consents for the release of medical records,                      Referral" in the "How to Obtain Services" section
assignments, claims for any other benefits to which you                    ♦ emergency ambulance Services as described under
may be entitled, or verification of your travel or itinerary.                  "Ambulance Services" in this "Benefits and Cost
                                                                               Sharing" section
We will send you our written decision within 45 business                   ♦ Emergency Services, Post-Stabilization Care, and
days after we receive the claim unless we request                              Out-of-Area Urgent Care as described in the
additional information from you or the Non–Plan                                "Emergency Services and Urgent Care" section
Provider. If we request additional information, we will                    ♦ hospice care as described under "Hospice Care" in
send our written decision no later than 45 business days                       this "Benefits and Cost Sharing" section


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 19
• The Medical Group has given prior authorization for              • If you receive more than one Service from a provider,
  the Services if required under "Medical Group                      or Services from more than one provider, you may be
  authorization procedure for certain referrals" in the              required to pay separate Cost Sharing amounts for
  "How to Obtain Services" section                                   each Service and each provider. For example, if you
                                                                     receive both preventive Services and non-preventive
The only Services we cover under this Membership                     Services in the same visit, you may have to pay
Agreement and Evidence of Coverage are those that this               separate Cost Sharing for each Service received
"Benefits and Cost Sharing" section says that we cover,              during that visit. Similarly, if your physician requests
subject to exclusions and limitations described in this              the assistance of another Plan Provider during a
"Benefits and Cost Sharing" section and to all provisions            procedure, you may have to pay separate Cost
in the "Exclusions, Limitations, Coordination of                     Sharing amounts for the Services provided by each
Benefits, and Reductions" section. The "Exclusions,                  Plan Provider. If you have questions about Cost
Limitations, Coordination of Benefits, and Reductions"               Sharing, please contact our Member Service Call
section describes exclusions, limitations, reductions, and           Center
coordination of benefits provisions that apply to all              • In some cases, we may agree to bill you for your Cost
Services that would otherwise be covered. When an                    Sharing amounts
exclusion or limitation applies only to a particular
benefit, it is listed in the description of that benefit in this   If you receive Services that are not covered under this
"Benefits and Cost Sharing" section. Also, please refer            Membership Agreement and Evidence of Coverage, you
to:                                                                may be liable for the full price of those Services.
• The "Emergency Services and Urgent Care" section
  for information about how to obtain covered                      Copayments and Coinsurance
  Emergency Services, Post-Stabilization Care, and                 The Copayment or Coinsurance you must pay for each
  Out-of-Area Urgent Care                                          covered Service is described in this "Benefits and Cost
• Your Guidebook for the types of covered Services                 Sharing" section.
  that are available from each Plan Facility in your
  area, because some facilities provide only specific              Annual out-of-pocket maximum
  types of covered Services                                        There is a limit to the total amount of Cost Sharing you
                                                                   must pay under this Membership Agreement and
                                                                   Evidence of Coverage in a calendar year for all of the
Cost Sharing                                                       covered Services listed below that you receive in the
                                                                   same calendar year. The limit is $2,500 per calendar
At the time you receive covered Services, you must pay
                                                                   year.
the Cost Sharing in effect on that date, except as follows:
• If you are receiving covered inpatient hospital or               Payments that count toward the maximum. The
  Skilled Nursing Facility Services on the effective date          Copayments and Coinsurance you pay for the following
  of this Membership Agreement and Evidence of                     Services apply toward the annual out-of-pocket
  Coverage, you pay the Cost Sharing in effect on your             maximum:
  admission date until you are discharged if the
                                                                   • Administered drugs
  Services were covered under your prior Health Plan
  evidence of coverage and there has been no break in              • Ambulance Services
  coverage. However, if the Services were not covered              • Amino acid–modified products used to treat
  under your prior Health Plan evidence of coverage, or              congenital errors of amino acid metabolism (such as
  if there has been a break in coverage, you pay the                 phenylketonuria)
  Cost Sharing in effect on the date you receive the
  Services                                                         • Diabetic testing supplies and equipment and insulin-
                                                                     administration devices
• For items ordered in advance, you pay the Cost
  Sharing in effect on the order date (although we will            • Emergency Department visits
  not cover the item unless you still have coverage for            • Home health care
  it on the date you receive it) and you may be required
                                                                   • Hospice care
  to pay the Cost Sharing when the item is ordered. For
  outpatient prescription drugs, the order date is the             • Hospital care
  date that the pharmacy processes the order after                 • Imaging, laboratory, and special procedures
  receiving all of the information they need to fill the
  prescription                                                     • Intensive psychiatric treatment programs


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                           Page 20
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Outpatient surgery                                                    The following are examples of preventive Services that
                                                                        are included in our "Health Reform Preventive Services
• Prosthetic and orthotic devices
                                                                        List - CA Regions":
• Services performed during an office visit (including
                                                                        • Eye exams for refraction and preventive vision
  professional Services such as dialysis treatment,
                                                                          screenings
  health education counseling and programs, and
  physical, occupational, and speech therapy)                           • Family planning counseling and programs
• Skilled Nursing Facility care                                         • Flexible sigmoidoscopies and colonoscopies
                                                                        • Health education counseling and programs
Keeping track of the maximum. When you pay Cost
Sharing that applies toward the annual out-of-pocket                    • Hearing exams and screenings
maximum, ask for and keep the receipt. When the                         • Immunizations (including vaccines) administered in a
receipts add up to the annual out-of-pocket maximum,                      Plan Medical Office
please call our Member Service Call Center to find out
                                                                        • Preventive counseling, such as STD prevention
where to turn in your receipts. When you turn them in,
                                                                          counseling
we will give you a document stating that you don't have
to pay any more Cost Sharing for Services subject to the                • Routine preventive imaging services, including the
annual out-of-pocket maximum through the end of the                       following:
calendar year.                                                            ♦ abdominal aortic aneurysm screening
                                                                           ♦ bone density scans

Preventive Care Services                                                   ♦ mammograms
                                                                           ♦ ultrasounds
We cover a variety of preventive care Services, which
are Services that do one or more of the following:                      • Routine physical maintenance exams, including well-
                                                                          woman exams
• Protect against disease, such as in the use of
  immunizations                                                         • Routine preventive retinal photography screenings

• Promote health, such as counseling on tobacco use                     • Scheduled prenatal care exams and first postpartum
                                                                          follow-up consultation and exam
• Detect disease in its earliest stages before noticeable
  symptoms develop, such as screening for breast                        • Tuberculosis tests
  cancer                                                                • Well-child preventive care exams (0–23 months)
                                                                        • The following laboratory tests:
This "Preventive Care Services" section explains Cost
                                                                           ♦ routine preventive laboratory tests, such as
Sharing for some preventive care Services, but does not
                                                                               cervical cancer screenings
otherwise explain coverage. These preventive care
Services are subject to all coverage requirements                          ♦ cholesterol tests (lipid panel and profile)
described in other parts of this "Benefits and Cost                        ♦ diabetes screening (fasting blood glucose tests)
Sharing" section and all provisions in the "Exclusions,                    ♦ fecal occult blood tests
Limitations, Coordination of Benefits, and Reductions"
                                                                           ♦ HIV tests
section. For example, we cover a preventive care Service
that is an outpatient laboratory Service only if it is                     ♦ prostate specific antigen tests
covered as described under the "Outpatient Imaging,                        ♦ certain sexually transmitted disease (STD) tests
Laboratory, and Special Procedures" section, subject to
the "Exclusions, Limitations, Coordination of Benefits,                 If you receive both preventive and non-preventive
and Reductions" section.                                                Services in the same visit, you may have to pay separate
                                                                        Cost Sharing amounts for each Service received during
We cover at no charge the preventive care Services                      that visit. For example, if you go in for a preventive
listed on our "Health Reform Preventive Services List -                 exam, and your physician diagnoses you with an
CA regions." This list is subject to change at any time                 infection, you may have to pay separate Cost Sharing
and is available from Member Services or on our website                 amounts for both the preventive exam and for the
at kp.org/formsandpubs. If you receive any other                        Services performed to diagnose a condition.
covered Services during a preventive care visit, you will
pay the applicable Cost Sharing for those Services.




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 21
Outpatient Care                                              • Voluntary termination of pregnancy: a
                                                               $25 Copayment per procedure
We cover the following outpatient care subject to the
                                                             • Physical, occupational, and speech therapy: a
Cost Sharing indicated:
                                                               $25 Copayment per visit
• Most primary and specialty care consultations and
                                                             • Physical, occupational, and speech therapy provided
  exams: a $25 Copayment per visit
                                                               in an organized, multidisciplinary rehabilitation day-
• Routine physical maintenance exams, including well-          treatment program: a $25 Copayment per day
  woman exams: no charge
                                                             • Urgent Care consultations and exams: a
• Well-child preventive exams for Members through              $25 Copayment per visit
  age 23 months: no charge
                                                             • Emergency Department visits: a $100 Copayment
• Family planning counseling, or to obtain internally          per visit. The Emergency Department Copayment
  implanted time-release contraceptives or intrauterine        does not apply if you are admitted directly to the
  devices (IUDs) prescribed in accord with our drug            hospital as an inpatient for covered Services, or if you
  formulary guidelines: no charge                              are admitted for observation and are then admitted
• After confirmation of pregnancy, the normal series of        directly to the hospital as an inpatient for covered
  regularly scheduled preventive care prenatal care            Services (for inpatient care, please refer to "Hospital
  exams and the first postpartum follow-up consultation        Inpatient Care" in this "Benefits and Cost Sharing"
  and exam: no charge                                          section). However, the Emergency Department
                                                               Copayment does apply if you are admitted for
• Alcohol and substance abuse interventions:                   observation but are not admitted as an inpatient
  no charge
                                                             • House calls by a Plan Physician (or a Plan Provider
• Developmental screenings to diagnose and assess              who is a registered nurse) inside our Service Area
  potential developmental delays: no charge                    when care can best be provided in your home as
• Immunizations (including vaccines) administered to           determined by a Plan Physician: no charge
  you in a Plan Medical Office: no charge                    • Acupuncture Services provided for the treatment of
• Flexible sigmoidoscopies: no charge                          nausea or as part of a multidisciplinary pain
                                                               management program for the treatment of chronic
• Colonoscopies: no charge
                                                               pain: a $25 Copayment per visit
• Allergy injections (including allergy serum): a
                                                             • Blood, blood products, and their administration:
  $5 Copayment per visit
                                                               no charge
• Outpatient surgery: a $100 Copayment per
                                                             • Administered drugs (drugs, injectables, radioactive
  procedure if it is provided in an outpatient or
                                                               materials used for therapeutic purposes, and allergy
  ambulatory surgery center or in a hospital operating
                                                               test and treatment materials) prescribed in accord
  room, or if it is provided in any setting and a licensed
                                                               with our drug formulary guidelines, if administration
  staff member monitors your vital signs as you regain
                                                               or observation by medical personnel is required and
  sensation after receiving drugs to reduce sensation or
                                                               they are administered to you in a Plan Medical Office
  to minimize discomfort. Any other outpatient surgery
                                                               or during home visits: no charge
  is covered at a $25 Copayment per procedure
                                                             • Some types of outpatient consultations and exams
• Outpatient procedures (other than surgery): a
                                                               may be available as group appointments, which we
  $100 Copayment per procedure if a licensed staff
                                                               cover at a $12 Copayment per visit
  member monitors your vital signs as you regain
  sensation after receiving drugs to reduce sensation or
                                                             Services not covered under this "Outpatient
  to minimize discomfort. All outpatient procedures
                                                             Care" section
  that do not require a licensed staff member to monitor
  your vital signs as described above are covered at the     The following types of outpatient Services are covered
  Cost Sharing that would otherwise apply for the            only as described under these headings in this "Benefits
  procedure in this "Benefits and Cost Sharing"              and Cost Sharing" section:
  section (for example, radiology procedures that do         • Bariatric Surgery
  not require a licensed staff member to monitor your
                                                             • Chemical Dependency Services
  vital signs as described above are covered under
  "Outpatient Imaging, Laboratory, and Special               • Dental and Orthodontic Services
  Procedures")                                               • Dialysis Care



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 22
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Durable Medical Equipment for Home Use                                   cesarean section), your Plan Physician may order a
                                                                           follow-up visit for you and your newborn to take
• Health Education
                                                                           place within 48 hours after discharge (for visits after
• Hearing Services                                                         you are released from the hospital, please refer to
• Home Health Care                                                         "Outpatient Care" in this "Benefits and Cost Sharing"
                                                                           section)
• Hospice Care
                                                                        • Physical, occupational, and speech therapy (including
• Mental Health Services                                                  treatment in an organized, multidisciplinary
• Ostomy and Urological Supplies                                          rehabilitation program)
• Outpatient Imaging, Laboratory, and Special                           • Respiratory therapy
  Procedures                                                            • Medical social services and discharge planning
• Outpatient Prescription Drugs, Supplies, and
  Supplements                                                           Services not covered under this "Hospital
• Prosthetic and Orthotic Devices                                       Inpatient Care" section
                                                                        The following types of inpatient Services are covered
• Reconstructive Surgery                                                only as described under the following headings in this
• Services Associated with Clinical Trials                              "Benefits and Cost Sharing" section:
• Transplant Services                                                   • Bariatric Surgery
• Vision Services                                                       • Chemical Dependency Services
                                                                        • Dental and Orthodontic Services
Hospital Inpatient Care                                                 • Dialysis Care
                                                                        • Hospice Care
We cover the following inpatient Services at a
$200 Copayment per day in a Plan Hospital, when the                     • Mental Health Services
Services are generally and customarily provided by acute                • Prosthetic and Orthotic Devices
care general hospitals inside our Service Area:
                                                                        • Reconstructive Surgery
• Room and board, including a private room
  if Medically Necessary                                                • Services Associated with Clinical Trials

• Specialized care and critical care units                              • Skilled Nursing Facility Care

• General and special nursing care                                      • Transplant Services

• Operating and recovery rooms
• Services of Plan Physicians, including consultation                  Ambulance Services
  and treatment by specialists
                                                                        Emergency
• Anesthesia                                                            We cover at a $100 Copayment per trip Services of a
• Drugs prescribed in accord with our drug formulary                    licensed ambulance anywhere in the world without prior
  guidelines (for discharge drugs prescribed when you                   authorization (including transportation through the 911
  are released from the hospital, please refer to                       emergency response system where available) if one of
  "Outpatient Prescription Drugs, Supplies, and                         the following is true:
  Supplements" in this "Benefits and Cost Sharing"                      • You reasonably believe that you have an Emergency
  section)                                                                Medical Condition and you reasonably believe that
• Radioactive materials used for therapeutic purposes                     your condition requires the clinical support of
                                                                          ambulance transport services
• Durable medical equipment and medical supplies
                                                                        • Your treating physician determines that you must be
• Imaging, laboratory, and special procedures,
                                                                          transported to another facility because your
  including MRI, CT, and PET scans
                                                                          Emergency Medical Condition is not Stabilized and
• Blood, blood products, and their administration                         the care you need is not available at the treating
• Obstetrical care and delivery (including cesarean                       facility
  section). Note: If you are discharged within 48 hours
  after delivery (or within 96 hours if delivery is by                  If you receive emergency ambulance Services that are
                                                                        not ordered by a Plan Provider, you must pay the


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 23
provider and file a claim for reimbursement unless the        • Transportation for you to and from the facility up to
provider agrees to bill us. Please refer to "Payment and        $130 per round trip for a maximum of three trips (one
Reimbursement" in the "Emergency Services and Urgent            pre-surgical visit, the surgery, and one follow-up
Care" section for how to file a claim for reimbursement.        visit), including any trips for which we provided
                                                                reimbursement under any other evidence of coverage
Nonemergency
                                                              • Transportation for one companion to and from the
Inside our Service Area, we cover nonemergency                  facility up to $130 per round trip for a maximum of
ambulance and psychiatric transport van Services at a           two trips (the surgery and one follow-up visit),
$100 Copayment per trip if a Plan Physician                     including any trips for which we provided
determines that your condition requires the use of              reimbursement under any other evidence of coverage
Services that only a licensed ambulance (or psychiatric
transport van) can provide and that the use of other          • One hotel room, double-occupancy, for you and one
means of transportation would endanger your health.             companion not to exceed $100 per day for the pre-
These Services are covered only when the vehicle                surgical visit and the follow-up visit, up to two days
transports you to or from covered Services.                     per trip, including any hotel accommodations for
                                                                which we provided reimbursement under any other
Ambulance Services exclusion                                    evidence of coverage

• Transportation by car, taxi, bus, gurney van,               • Hotel accommodations for one companion not to
  wheelchair van, and any other type of transportation          exceed $100 per day for the duration of your surgery
  (other than a licensed ambulance or psychiatric               stay, up to four days, including any hotel
  transport van), even if it is the only way to travel to a     accommodations for which we provided
  Plan Provider                                                 reimbursement under any other evidence of coverage

                                                              Services not covered under this "Bariatric
Bariatric Surgery                                             Surgery" section
                                                              Coverage for the following Services is described under
We cover hospital inpatient care related to bariatric         these headings in this "Benefits and Cost Sharing"
surgical procedures (including room and board, imaging,       section:
laboratory, special procedures, and Plan Physician
                                                              • Outpatient prescription drugs (refer to "Outpatient
Services) when performed to treat obesity by
                                                                Prescription Drugs, Supplies, and Supplements")
modification of the gastrointestinal tract to reduce
nutrient intake and absorption, if all of the following
requirements are met:                                         Chemical Dependency Services
• You complete the Medical Group–approved pre-
  surgical educational preparatory program regarding          Inpatient detoxification
  lifestyle changes necessary for long term bariatric         We cover hospitalization at a $200 Copayment per day
  surgery success                                             in a Plan Hospital only for medical management of
                                                              withdrawal symptoms, including room and board, Plan
• A Plan Physician who is a specialist in bariatric care
                                                              Physician Services, drugs, dependency recovery
  determines that the surgery is Medically Necessary
                                                              Services, education, and counseling.
For covered Services related to bariatric surgical            Outpatient chemical dependency care
procedures that you receive, you will pay the Cost
                                                              We cover the following Services for treatment of
Sharing you would pay if the Services were not
                                                              chemical dependency:
related to a bariatric surgical procedure.
                                                              • Day-treatment programs
If you live 50 miles or more from the facility to which       • Intensive outpatient programs
you are referred for a covered bariatric surgery, we will
reimburse you for certain travel and lodging expenses if      • Individual and group chemical dependency
you receive prior written authorization from the Medical        counseling
Group and send us adequate documentation including            • Outpatient chemical dependency consultation and
receipts. We will not, however, reimburse you for any           treatment for withdrawal symptoms
travel or lodging expenses if you were offered a referral
to a facility that is less than 50 miles from your home.
We will reimburse authorized and documented travel and
lodging expenses as follows:


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 24
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
You pay the following for these covered Services:                       to a dentist (as described in "Medical Group
• Individual chemical dependency consultations and                      authorization procedure for certain referrals" under
  treatment: a $25 Copayment per visit                                  "Getting a Referral" in the "How to Obtain Services"
                                                                        section).
• Group chemical dependency treatments: a
  $5 Copayment per visit                                                Dental anesthesia
                                                                        For dental procedures at a Plan Facility, we provide
We cover methadone maintenance treatment at                             general anesthesia and the facility's Services associated
no charge for pregnant Members during pregnancy and                     with the anesthesia if all of the following are true:
for two months after delivery at a licensed treatment
center approved by the Medical Group. We do not cover                   • You are under age 7, or you are developmentally
methadone maintenance treatment in any other                              disabled, or your health is compromised
circumstances.                                                          • Your clinical status or underlying medical condition
                                                                          requires that the dental procedure be provided in a
Transitional residential recovery Services                                hospital or outpatient surgery center
We cover up to 60 days per calendar year of chemical                    • The dental procedure would not ordinarily require
dependency treatment in a nonmedical transitional                         general anesthesia
residential recovery setting approved in writing by the
Medical Group. We cover these Services at a                             We do not cover any other Services related to the dental
$100 Copayment per admission. We do not cover more                      procedure, such as the dentist's Services.
than 120 days of covered care in any five-consecutive-
calendar-year period. These settings provide counseling
                                                                        For covered dental anesthesia Services, you will pay the
and support services in a structured environment.
                                                                        Cost Sharing that you would pay for hospital
                                                                        inpatient care or outpatient surgery, depending on
Services not covered under this "Chemical
                                                                        the setting.
Dependency Services" section
Coverage for the following Services is described under                  Dental and orthodontic Services for cleft palate
these headings in this "Benefits and Cost Sharing"
                                                                        We cover dental extractions, dental procedures necessary
section:
                                                                        to prepare the mouth for an extraction, and orthodontic
• Outpatient self-administered drugs (refer to                          Services, if they meet all of the following requirements:
  "Outpatient Prescription Drugs, Supplies, and
                                                                        • The Services are an integral part of a reconstructive
  Supplements")
                                                                          surgery for cleft palate that we are covering under
• Outpatient laboratory (refer to "Outpatient Imaging,                    "Reconstructive Surgery" in this "Benefits and Cost
  Laboratory, and Special Procedures")                                    Sharing" section
                                                                        • A Plan Provider provides the Services or the Medical
Chemical dependency Services exclusion
                                                                          Group authorizes a referral to a Non-Plan Provider
• Services in a specialized facility for alcoholism, drug                 who is a dentist or orthodontist (as described in
  abuse, or drug addiction except as otherwise                            "Medical Group authorization procedure for certain
  described in this "Chemical Dependency Services"                        referrals" under "Getting a Referral" in the "How to
  section                                                                 Obtain Services" section)

                                                                        You pay the following for these dental and orthodontic
Dental and Orthodontic Services                                         Services for cleft palate:
We do not cover most dental and orthodontic Services,                   • Consultations and exams: a $25 Copayment per visit
but we do cover some dental and orthodontic Services as                 • Hospital inpatient care: a $200 Copayment per day
described in this "Dental and Orthodontic Services"
section.                                                                • Outpatient surgery: a $100 Copayment per
                                                                          procedure if it is provided in an outpatient or
Dental Services for radiation treatment                                   ambulatory surgery center or in a hospital operating
                                                                          room, or if it is provided in any setting and a licensed
We cover dental evaluation, X-rays, fluoride treatment,
                                                                          staff member monitors your vital signs as you regain
and extractions necessary to prepare your jaw for
                                                                          sensation after receiving drugs to reduce sensation or
radiation therapy of cancer in your head or neck at a
                                                                          to minimize discomfort. Any other outpatient surgery:
$25 Copayment per visit if a Plan Physician provides
                                                                          a $25 Copayment per procedure
the Services or if the Medical Group authorizes a referral


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 25
• Outpatient procedures (other than surgery): a              You pay the following for these covered Services related
  $100 Copayment per procedure if a licensed staff           to dialysis:
  member monitors your vital signs as you regain             • Inpatient dialysis care: a $200 Copayment per day
  sensation after receiving drugs to reduce sensation or
  to minimize discomfort. All outpatient procedures          • One routine office consultation or exam per month
  that do not require a licensed staff member to monitor       with the multidisciplinary nephrology team:
  your vital signs as described above are covered at the       no charge
  Cost Sharing that would otherwise apply for the            • All other consultations or exams: a $25 Copayment
  procedure in this "Benefits and Cost Sharing"                per visit
  section (for example, radiology procedures that do
                                                             • Hemodialysis treatment at a Plan Facility: a
  not require a licensed staff member to monitor your
                                                               $25 Copayment per visit
  vital signs as described above are covered under
  "Outpatient Imaging, Laboratory, and Special
                                                             Services not covered under this "Dialysis Care"
  Procedures")
                                                             section
Services not covered under this "Dental and                  Coverage for the following Services is described under
Orthodontic Services" section                                these headings in this "Benefits and Cost Sharing"
                                                             section:
Coverage for the following Services is described under
these headings in this "Benefits and Cost Sharing"           • Durable medical equipment for home use (refer to
section:                                                       "Durable Medical Equipment for Home Use")
• Outpatient imaging, laboratory, and special                • Outpatient laboratory (refer to "Outpatient Imaging,
  procedures (refer to "Outpatient Imaging, Laboratory,        Laboratory, and Special Procedures")
  and Special Procedures")                                   • Outpatient prescription drugs (refer to "Outpatient
• Outpatient administered drugs (refer to "Outpatient          Prescription Drugs, Supplies, and Supplements")
  Care"), except that we cover outpatient administered       • Outpatient administered drugs (refer to "Outpatient
  drugs under "Dental anesthesia" in this "Dental and          Care")
  Orthodontic Services" section
• Outpatient prescription drugs (refer to "Outpatient        Dialysis Care exclusions
  Prescription Drugs, Supplies, and Supplements")            • Comfort, convenience, or luxury equipment, supplies
                                                               and features
Dialysis Care                                                • Nonmedical items, such as generators or accessories
                                                               to make home dialysis equipment portable for travel
We cover acute and chronic dialysis Services if all of the
following requirements are met:
• The Services are provided inside our Service Area          Durable Medical Equipment for Home
                                                             Use
• You satisfy all medical criteria developed by the
  Medical Group and by the facility providing the            Inside our Service Area, we cover the durable medical
  dialysis                                                   equipment specified in this "Durable Medical Equipment
• A Plan Physician provides a written referral for care      for Home Use" section for use in your home (or another
  at the facility                                            location used as your home) in accord with our durable
                                                             medical equipment formulary guidelines. Durable
After you receive appropriate training at a dialysis         medical equipment for home use is an item that is
facility we designate, we also cover equipment and           intended for repeated use, primarily and customarily
medical supplies required for home hemodialysis and          used to serve a medical purpose, generally not useful to a
home peritoneal dialysis inside our Service Area at          person who is not ill or injured, and appropriate for use
no charge. Coverage is limited to the standard item of       in the home.
equipment or supplies that adequately meets your
medical needs. We decide whether to rent or purchase         Coverage is limited to the standard item of equipment
the equipment and supplies, and we select the vendor.        that adequately meets your medical needs. Covered
You must return the equipment and any unused supplies        durable medical equipment (including repair or
to us or pay us the fair market price of the equipment and   replacement of covered equipment, unless due to loss or
any unused supply when we are no longer covering             misuse) is provided at 20% Coinsurance. We decide
them.                                                        whether to rent or purchase the equipment, and we select


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 26
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
the vendor. You must return the equipment to us or pay                  • Peak flow meters from a Plan Pharmacy
us the fair market price of the equipment when we are no
longer covering it.                                                     About our durable medical equipment formulary
                                                                        Our durable medical equipment formulary includes the
Inside our Service Area, we cover the following durable                 list of durable medical equipment that has been approved
medical equipment for use in your home (or another                      by our Durable Medical Equipment Formulary Executive
location used as your home):                                            Committee for our Members. Our durable medical
• For diabetes blood testing, blood glucose monitors                    equipment formulary was developed by a
  and their supplies (such as blood glucose monitor test                multidisciplinary clinical and operational work group
  strips, lancets, and lancet devices)                                  with review and input from Plan Physicians and medical
                                                                        professionals with durable medical equipment expertise
• Infusion pumps (such as insulin pumps) and supplies                   (for example: physical, respiratory, and enterostomal
  to operate the pump (but not including insulin or any                 therapists and home health). A multidisciplinary Durable
  other drugs)                                                          Medical Equipment Formulary Executive Committee is
• Standard curved handle or quad cane and replacement                   responsible for reviewing and revising the durable
  supplies                                                              medical equipment formulary. Our durable medical
                                                                        equipment formulary is periodically updated to keep
• Standard or forearm crutches and replacement
                                                                        pace with changes in medical technology and clinical
  supplies
                                                                        practice.
• Dry pressure pad for a mattress
• Nebulizer and supplies                                                Our formulary guidelines allow you to obtain
                                                                        nonformulary durable medical equipment (equipment not
• Peak flow meters
                                                                        listed on our durable medical equipment formulary for
• IV pole                                                               your condition) if the equipment would otherwise be
• Tracheostomy tube and supplies                                        covered and the Medical Group determines that it is
                                                                        Medically Necessary as described in "Medical Group
• Enteral pump and supplies                                             authorization procedure for certain referrals" under
• Bone stimulator                                                       "Getting a Referral" in the "How to Obtain Services"
                                                                        section.
• Cervical traction (over door)
• Phototherapy blankets for treatment of jaundice in                    Services not covered under this "Durable
  newborns                                                              Medical Equipment for Home Use" section
                                                                        Coverage for the following Services is described under
Outside the Service Area                                                these headings in this "Benefits and Cost Sharing"
We do not cover most durable medical equipment for                      section:
home use outside our Service Area. However, if you live
                                                                        • Dialysis equipment and supplies required for home
outside our Service Area, we cover the following durable
                                                                          hemodialysis and home peritoneal dialysis (refer to
medical equipment (subject to the Cost Sharing and all
                                                                          "Dialysis Care")
other coverage requirements that apply to durable
medical equipment for home use inside our Service                       • Diabetes urine testing supplies and insulin-
Area) when the item is dispensed at a Plan Facility:                      administration devices other than insulin pumps (refer
                                                                          to "Outpatient Prescription Drugs, Supplies, and
• Standard curved handle cane
                                                                          Supplements")
• Standard crutches
                                                                        • Durable medical equipment related to the terminal
• For diabetes blood testing, blood glucose monitors                      illness for Members who are receiving covered
  and their supplies (such as blood glucose monitor test                  hospice care (refer to "Hospice Care")
  strips, lancets, and lancet devices) from a Plan
  Pharmacy                                                              Durable medical equipment for home use
• Insulin pumps and supplies to operate the pump (but                   exclusion
  not including insulin or any other drugs), after                      • Comfort, convenience, or luxury equipment or
  completion of training and education on the use of the                  features
  pump
• Nebulizers and their supplies for the treatment of
  pediatric asthma



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 27
Health Education                                             Hearing Services exclusions
                                                             • Hearing aids and tests to determine their efficacy, and
We cover a variety of health education counseling,
                                                               hearing tests to determine an appropriate hearing aid
programs, and materials that your personal Plan
Physician or other Plan Providers provide during a visit
covered under another part of this "Benefits and Cost        Home Health Care
Sharing" section.
                                                             "Home health care" means Services provided in the
We also cover a variety of health education counseling,      home by nurses, medical social workers, home health
programs, and materials to help you take an active role in   aides, and physical, occupational, and speech therapists.
protecting and improving your health, including              We cover home health care at no charge only if all of
programs for tobacco cessation, stress management, and       the following are true:
chronic conditions (such as diabetes and asthma). Kaiser
                                                             • You are substantially confined to your home (or a
Permanente also offers health education counseling,
                                                               friend's or relative's home)
programs, and materials that are not covered, and you
may be required to pay a fee.                                • Your condition requires the Services of a nurse,
                                                               physical therapist, occupational therapist, or speech
For more information about our health education                therapist (home health aide Services are not covered
counseling, programs, and materials, please contact your       unless you are also getting covered home health care
local Health Education Department or our Member                from a nurse, physical therapist, occupational
Service Call Center, refer to Your Guidebook, or go to         therapist, or speech therapist that only a licensed
our website at kp.org.                                         provider can provide)
                                                             • A Plan Physician determines that it is feasible to
You pay the following for these covered Services:              maintain effective supervision and control of your
• Group health education programs: no charge                   care in your home and that the Services can be safely
                                                               and effectively provided in your home
• Individual counseling and programs when the visit is
  solely for health education: no charge                     • The Services are provided inside our Service Area

• Health education provided during an outpatient             We cover only part-time or intermittent home health
  consultation or exam covered in another part of this       care, as follows:
  "Benefits and Cost Sharing" section: no additional
  Cost Sharing beyond the Cost Sharing required in           • Up to two hours per visit for visits by a nurse,
  that other part of this "Benefits and Cost                   medical social worker, or physical, occupational, or
  Sharing" section                                             speech therapist, and up to four hours per visit for
                                                               visits by a home health aide
• Covered health education materials: no charge
                                                             • Up to three visits per day (counting all home health
                                                               visits)
Hearing Services                                             • Up to 100 visits per calendar year (counting all home
                                                               health visits)
We cover the following:
• Routine preventive hearing screenings: no charge           Note: If a visit by a nurse, medical social worker, or
• Hearing exams to determine the need for hearing            physical, occupational, or speech therapist lasts longer
  correction: no charge                                      than two hours, then each additional increment of two
                                                             hours counts as a separate visit. If a visit by a home
Services not covered under this "Hearing                     health aide lasts longer than four hours, then each
Services" section                                            additional increment of four hours counts as a separate
Coverage for the following Services is described under       visit. For example, if a nurse comes to your home for
these headings in this "Benefits and Cost Sharing"           three hours and then leaves, that counts as two visits.
section:                                                     Also, each person providing Services counts toward
                                                             these visit limits. For example, if a home health aide and
• Services related to the ear or hearing other than those    a nurse are both at your home during the same two hours,
  described in this section (refer to the applicable         that counts as two visits.
  heading in this "Benefits and Cost Sharing" section)
• Cochlear implants and osseointegrated hearing
  devices (refer to "Prosthetic and Orthotic Devices")


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 28
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
The following types of Services are covered only as                     If all of the above requirements are met, we cover the
described under these headings in this "Benefits and Cost               following hospice Services, which are available on a 24-
Sharing" section:                                                       hour basis if necessary for your hospice care:
• Dialysis Care                                                         • Plan Physician Services
• Durable Medical Equipment for Home Use                                • Skilled nursing care, including assessment,
• Ostomy and Urological Supplies                                          evaluation, and case management of nursing needs,
                                                                          treatment for pain and symptom control, provision of
• Outpatient Prescription Drugs, Supplies, and                            emotional support to you and your family, and
  Supplements                                                             instruction to caregivers
• Prosthetic and Orthotic Devices                                       • Physical, occupational, or speech therapy for
                                                                          purposes of symptom control or to enable you to
Home health care exclusions                                               maintain activities of daily living
• Care of a type that an unlicensed family member or                    • Respiratory therapy
  other layperson could provide safely and effectively
                                                                        • Medical social services
  in the home setting after receiving appropriate
  training. This care is excluded even if we would                      • Home health aide and homemaker services
  cover the care if it were provided by a qualified                     • Palliative drugs prescribed for pain control and
  medical professional in a hospital or a Skilled                         symptom management of the terminal illness for up
  Nursing Facility                                                        to a 100-day supply in accord with our drug
• Care in the home if the home is not a safe and                          formulary guidelines. You must obtain these drugs
  effective treatment setting                                             from Plan Pharmacies. Certain drugs are limited to a
                                                                          maximum 30-day supply in any 30-day period (please
                                                                          call our Member Service Call Center for the current
Hospice Care                                                              list of these drugs)
Hospice care is a specialized form of interdisciplinary                 • Durable medical equipment
health care designed to provide palliative care and to                  • Respite care when necessary to relieve your
alleviate the physical, emotional, and spiritual                          caregivers. Respite care is occasional short-term
discomforts of a Member experiencing the last phases of                   inpatient care limited to no more than five
life due to a terminal illness. It also provides support to               consecutive days at a time
the primary caregiver and the Member's family. A
                                                                        • Counseling and bereavement services
Member who chooses hospice care is choosing to receive
palliative care for pain and other symptoms associated                  • Dietary counseling
with the terminal illness, but not to receive care to try to            • The following care during periods of crisis when you
cure the terminal illness. You may change your decision                   need continuous care to achieve palliation or
to receive hospice care benefits at any time.                             management of acute medical symptoms:
                                                                          ♦ nursing care on a continuous basis for as much as
We cover the hospice Services listed below at no charge
                                                                             24 hours a day as necessary to maintain you at
only if all of the following requirements are met:
                                                                             home
• A Plan Physician has diagnosed you with a terminal                       ♦ short-term inpatient care required at a level that
  illness and determines that your life expectancy is 12                       cannot be provided at home
  months or less
• The Services are provided inside our Service Area or
  inside California but within 15 miles or 30 minutes                  Mental Health Services
  from our Service Area (including a friend's or
                                                                        We cover Services specified in this "Mental Health
  relative's home even if you live there temporarily)
                                                                        Services" section only when the Services are for the
• The Services are provided by a licensed hospice                       diagnosis or treatment of Mental Disorders.
  agency that is a Plan Provider
• The Services are necessary for the palliation and                     A Mental Disorder is a mental health condition as
  management of your terminal illness and related                       identified in the Diagnostic and Statistical Manual of
  conditions                                                            Mental Disorders, Fourth Edition, Text Revision (DSM)
                                                                        that results in clinically significant distress or impairment
                                                                        of mental, emotional, or behavioral functioning.



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 29
Mental Disorders include the Severe Mental Illness of a         Services for mental health evaluation and treatment as
person of any age and the Serious Emotional Disturbance         described in this "Outpatient mental health Services"
of a Child:                                                     section. Members who have exhausted the 20-visit
• "Severe Mental Illness" means the following mental            limitation and who meet Medical Group criteria may
  disorders: schizophrenia, schizoaffective disorder,           receive up to 20 additional group visits in the same
  bipolar disorder (manic-depressive illness), major            calendar year
  depressive disorders, panic disorder, obsessive-           • Psychological testing when necessary to evaluate a
  compulsive disorder, pervasive developmental                 Mental Disorder
  disorder or autism, anorexia nervosa, and bulimia          • Outpatient Services for the purpose of monitoring
  nervosa.                                                     drug therapy
• A "Serious Emotional Disturbance" of a child under
  age 18 means mental disorders as identified in the         You pay the following for these covered Services:
  DSM, other than a primary substance use disorder or
                                                             • Individual mental health evaluation and treatment: a
  developmental disorder, that results in behavior
                                                               $25 Copayment per visit
  inappropriate to the child's age according to expected
  developmental norms, if the child also meets at least      • Group mental health treatment: a $12 Copayment
  one of the following three criteria:                         per visit
  ♦ as a result of the mental disorder the child has
     substantial impairment in at least two of the           Note: Outpatient intensive psychiatric treatment
     following areas: self-care, school functioning,         programs are not covered under this "Outpatient mental
     family relationships, or ability to function in the     health Services" section (refer to "Intensive psychiatric
     community; and either (1) the child is at risk of       treatment programs" under "Inpatient psychiatric
     removal from the home or has already been               hospitalization and intensive psychiatric treatment
     removed from the home, or (2) the mental disorder       programs" in this "Mental Health Services" section).
     and impairments have been present for more than
     six months or are likely to continue for more than      Inpatient psychiatric hospitalization and
     one year without treatment                              intensive psychiatric treatment programs
   ♦ the child displays psychotic features, or risk of       Inpatient psychiatric hospitalization. Subject to the
       suicide or violence due to a mental disorder          day limit described under "Calendar-year day limit for
   ♦ the child meets special education eligibility           inpatient psychiatric hospitalization and intensive
       requirements under Chapter 26.5 (commencing           psychiatric treatment programs" in this "Inpatient
       with Section 7570) of Division 7 of Title 1 of the    psychiatric hospitalization and intensive psychiatric
       California Government Code                            treatment programs" section, we cover inpatient
                                                             psychiatric hospitalization in a Plan Hospital. Coverage
Any outpatient visit limits specified under "Outpatient      includes room and board, drugs, and Services of Plan
mental health Services" and inpatient day limits specified   Physicians or other Plan Providers who are licensed
under "Calendar-year day limit for inpatient psychiatric     health care professionals acting within the scope of their
hospitalization and intensive psychiatric treatment          license. We cover these Services at a $200 Copayment
programs" do not apply to Severe Mental Illness of a         per day.
person of any age and the Serious Emotional Disturbance
of a child. For all other mental health conditions, we       Intensive psychiatric treatment programs. Subject to
cover evaluation and treatment only when a Plan              the day limit described under "Calendar-year day limit
Physician or other Plan Provider who is a license health     for inpatient psychiatric hospitalization and intensive
care professional acting within the scope of his or her      psychiatric treatment programs" in this "Inpatient
license believes the condition will significantly improve    psychiatric hospitalization and intensive psychiatric
with relatively short-term therapy.                          treatment programs" section, we cover at no charge the
                                                             following intensive psychiatric treatment programs at a
Outpatient mental health Services                            Plan Facility:
We cover the following Services when provided by Plan        • Short-term hospital-based intensive outpatient care
Physicians or other Plan Providers who are licensed            (partial hospitalization)
health care professionals acting within the scope of their   • Short-term multidisciplinary treatment in an intensive
license:                                                       outpatient psychiatric treatment program
• Up to a combined visit limit of 20 individual and
  group visits per Member calendar year that include


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 30
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Short-term treatment in a crisis residential program in              Ostomy and Urological Supplies
  licensed psychiatric treatment facility with 24-hour-a-
  day monitoring by clinical staff for stabilization of an              Inside our Service Area, we cover ostomy and urological
  acute psychiatric crisis                                              supplies prescribed in accord with our soft goods
                                                                        formulary guidelines at no charge. We select the vendor,
• Psychiatric observation for an acute psychiatric crisis
                                                                        and coverage is limited to the standard supply that
                                                                        adequately meets your medical needs.
Calendar-year day limit for inpatient psychiatric
hospitalization and intensive psychiatric treatment                     About our soft goods formulary
programs. There is a combined day limit of 30 days per
                                                                        Our soft goods formulary includes the list of ostomy and
Member per calendar year for psychiatric care described
                                                                        urological supplies that have been approved by our Soft
under "Inpatient psychiatric hospitalization" and
                                                                        Goods Formulary Executive Committee for our
"Intensive psychiatric treatment programs" in this
                                                                        Members. Our Soft Goods Formulary Executive
"Inpatient psychiatric hospitalization and intensive
                                                                        Committee is responsible for reviewing and revising the
psychiatric treatment programs" section, except that the
                                                                        soft goods formulary. Our soft goods formulary is
day limit does not apply to psychiatric care for the
                                                                        periodically updated to keep pace with changes in
treatment of Severe Mental Illnesses and Serious
                                                                        medical technology and clinical practice. To find out
Emotional Disturbance of a child under age 18. The
                                                                        whether a particular ostomy or urological supply is
number of days is determined by adding up the number
                                                                        included in our soft goods formulary, please call our
of days of inpatient psychiatric hospitalization and
                                                                        Member Service Call Center.
intensive psychiatric treatment program Services we
cover in a calendar year that are subject to the limit as
follows:                                                                Our formulary guidelines allow you to obtain
                                                                        nonformulary ostomy and urological supplies (those not
• Each day of inpatient psychiatric hospitalization                     listed on our soft goods formulary for your condition)
  counts as one day                                                     if they would otherwise be covered and the Medical
• Two days of hospital-based intensive outpatient care                  Group determines that they are Medically Necessary as
  (partial hospitalization) count as one day                            described in "Medical Group authorization procedure for
                                                                        certain referrals" under "Getting a Referral" in the "How
• Three days of treatment in an intensive outpatient
                                                                        to Obtain Services" section.
  psychiatric treatment program count as one day
• Each day of treatment in a crisis residential program                 Ostomy and urological supplies exclusion
  counts as one day
                                                                        • Comfort, convenience, or luxury equipment or
• Two psychiatric observation treatment periods of 23                     features
  consecutive hours or less count as one day

If you reach the day limit, we will not cover any more                 Outpatient Imaging, Laboratory, and
inpatient psychiatric hospitalization or intensive                     Special Procedures
psychiatric treatment program Services in that calendar
year if they are subject to the day limit.                              We cover the following Services at the Cost Sharing
                                                                        indicated only when prescribed as part of care covered
Services not covered under this "Mental Health                          under other headings in this "Benefits and Cost Sharing"
Services" section                                                       section:
Coverage for the following Services is described under                  • Most diagnostic and therapeutic imaging, such as X-
these headings in this "Benefits and Cost Sharing"                        rays, mammograms, and ultrasounds: a
section:                                                                  $10 Copayment per encounter except that certain
• Outpatient drugs, supplies, and supplements (refer to                   imaging procedures are covered at a
  "Outpatient Prescription Drugs, Supplies, and                           $100 Copayment per procedure if they are provided
  Supplements")                                                           in an outpatient or ambulatory surgery center or in a
                                                                          hospital operating room, or if they are provided in
• Outpatient laboratory (refer to "Outpatient Imaging,                    any setting and a licensed staff member monitors
  Laboratory, and Special Procedures")                                    your vital signs as you regain sensation after
                                                                          receiving drugs to reduce sensation or to minimize
                                                                          discomfort




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 31
• Preventive imaging, such as preventive                           ♦ Non–Plan Physicians if the Medical Group
  mammograms, aortic aneurysm screenings, and bone                    authorizes a written referral to the Non–Plan
  density screenings: no charge                                       Physician (in accord with "Medical Group
                                                                      authorization procedure for certain referrals" under
• MRI, most CT, and PET scans: a $50 Copayment
                                                                      "Getting a Referral" in the "How to Obtain
  per procedure
                                                                      Services" section) and the drug, supply, or
• Nuclear medicine: a $10 Copayment per encounter                     supplement is covered as part of that referral
• Laboratory tests (including tests for specific genetic           ♦ Non–Plan Physicians if the prescription was
  disorders for which genetic counseling is available):               obtained as part of covered Emergency Services,
   ♦ laboratory tests to monitor the effectiveness of                 Post-Stabilization Care, or Out-of-Area Urgent
       dialysis: no charge                                            Care described in the "Emergency Services and
                                                                      Urgent Care" section (if you fill the prescription at
   ♦ fecal occult blood tests: no charge
                                                                      a Plan Pharmacy, you may have to pay Charges
   ♦ preventive laboratory tests and screenings,                      for the item and file a claim for reimbursement as
       including cervical cancer screenings, prostate                 described under "Payment and Reimbursement" in
       specific antigen tests, cholesterol tests (lipid panel         the "Emergency Services and Urgent Care"
       and profile), diabetes screening (fasting blood                section)
       glucose tests), certain sexually transmitted disease
       (STD) tests, and HIV tests: no charge                    How to obtain covered items
   ♦ all other laboratory tests: a $10 Copayment per            You must obtain covered drugs, supplies, and
       encounter                                                supplements from a Plan Pharmacy or through our mail-
• Routine preventive retinal photography screenings:            order service unless the item is covered Emergency
  no charge                                                     Services, Post-Stabilization Care, or Out-of-Area Urgent
                                                                Care described in the "Emergency Services and Urgent
• All other diagnostic procedures provided by Plan              Care" section.
  Providers who are not physicians (such as EKGs and
  EEGs): a $10 Copayment per encounter except that
                                                                Please refer to Your Guidebook for the locations of Plan
  certain diagnostic procedures are covered at a
                                                                Pharmacies in your area.
  $100 Copayment per procedure if they are provided
  in an outpatient or ambulatory surgery center or in a
                                                                Refills. You may be able to order refills from a Plan
  hospital operating room, or if they are provided in
                                                                Pharmacy, our mail-order service, or through our website
  any setting and a licensed staff member monitors
                                                                at kp.org/rxrefill. A Plan Pharmacy or Your Guidebook
  your vital signs as you regain sensation after
                                                                can give you more information about obtaining refills,
  receiving drugs to reduce sensation or to minimize
                                                                including the options available to you for obtaining
  discomfort
                                                                refills. For example, a few Plan Pharmacies don't
• Radiation therapy: no charge                                  dispense refills and not all drugs can be mailed through
• Ultraviolet light treatments: no charge                       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 obtained from a Plan
Outpatient Prescription Drugs, Supplies,                        Pharmacy. Items available through our mail-order
and Supplements                                                 service are subject to change at any time without notice.

We cover outpatient drugs, supplies, and supplements            Outpatient drugs, supplies, and supplements
specified in this "Outpatient Prescription Drugs,               We cover the following outpatient drugs, supplies, and
Supplies, and Supplements" section when prescribed as           supplements:
follows and obtained through a Plan Pharmacy or our
                                                                • Drugs for which a prescription is required by law. We
mail-order service:
                                                                  also cover certain drugs that do not require a
• Items prescribed by Plan Physicians in accord with              prescription by law if they are listed on our drug
  our drug formulary guidelines                                   formulary. Note: Certain tobacco-cessation drugs are
• Items prescribed by the following Non–Plan                      covered only if you participate in a behavioral
  Providers unless a Plan Physician determines that the           intervention program approved by the Medical Group
  item is not Medically Necessary or the drug is for a          • Diaphragms, cervical caps, contraceptive rings,
  sexual dysfunction disorder:                                    contraceptive patches, and oral contraceptives
  ♦ Dentists if the drug is for dental care                       (including emergency contraceptive pills)



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                         Page 32
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Disposable needles and syringes needed for injecting                  Note: If Charges for the drug, supply, or supplement are
  covered drugs                                                         less than the Copayment, you will pay the lesser amount.
• Inhaler spacers needed to inhale covered drugs
                                                                        Certain intravenous drugs, supplies, and
                                                                        supplements
Cost Sharing for outpatient drugs, supplies, and
supplements. The Cost Sharing for these items is as                     We cover certain self-administered intravenous drugs,
follows:                                                                fluids, additives, and nutrients that require specific types
                                                                        of parenteral-infusion (such as an intravenous or
• Generic items:                                                        intraspinal-infusion) at no charge for up to a 30-day
   ♦ a $10 Copayment for up to a 30-day supply, a                       supply and the supplies and equipment required for their
       $20 Copayment for a 31- to 60-day supply, or a                   administration at no charge. Note: Injectable drugs and
       $30 Copayment for a 61- to 100-day supply at a                   insulin are not covered under this paragraph (instead,
       Plan Pharmacy                                                    refer to the "Outpatient drugs, supplies, and
   ♦ a $10 Copayment for up to a 30-day supply or a                     supplements" paragraph).
       $20 Copayment for a 31- to 100-day supply
       through our mail-order service                                   Diabetes urine-testing supplies and insulin-
                                                                        administration devices
   ♦ drugs prescribed for the treatment of sexual
       dysfunction disorders: 50% Coinsurance for up                    We cover ketone test strips and sugar or acetone test
       to a 100-day supply at a Plan Pharmacy or through                tablets or tapes for diabetes urine testing at no charge for
       our mail-order service                                           up to a 100-day supply.

• Brand-name items and compounded products:                             We cover the following insulin-administration devices at
   ♦ a $35 Copayment for up to a 30-day supply, a                       a $10 Copayment for up to a 100-day supply: pen
       $70 Copayment for a 31- to 60-day supply, or a                   delivery devices, disposable needles and syringes, and
       $105 Copayment for a 61- to 100-day supply at a                  visual aids required to ensure proper dosage (except
       Plan Pharmacy                                                    eyewear).
   ♦ a $35 Copayment for up to a 30-day supply or a
       $70 Copayment for a 31- to 100-day supply                        Day supply limit
       through our mail-order service                                   The prescribing physician or dentist determines how
   ♦ drugs prescribed for the treatment of sexual                       much of a drug, supply, or supplement to prescribe. For
       dysfunction disorders: 50% Coinsurance for up                    purposes of day supply coverage limits, Plan Physicians
       to a 100-day supply at a Plan Pharmacy or through                determine the amount of an item that constitutes a
       our mail-order service                                           Medically Necessary 30-, 60-, or 100-day supply for you.
                                                                        Upon payment of the Cost Sharing specified in this
• Amino acid–modified products used to treat                            "Outpatient Prescription Drugs, Supplies, and
  congenital errors of amino acid metabolism (such as                   Supplements" section, you will receive the supply
  phenylketonuria) and elemental dietary enteral                        prescribed up to the day supply limit also specified in
  formula when used as a primary therapy for regional                   this section. The day supply limit is either a 30-day
  enteritis: no charge for up to a 30-day supply                        supply in a 30-day period or a 100-day supply in a 100-
• Emergency contraceptive pills: no charge                              day period. If you wish to receive more than the covered
• Hematopoietic agents for dialysis: no charge for up                   day supply limit, then you must pay Charges for any
                                                                        prescribed quantities that exceed the day supply limit.
  to a 30-day supply
                                                                        Note: We cover episodic drugs prescribed for the
• Continuity drugs (if this Membership Agreement and                    treatment of sexual dysfunction disorders up to a
  Evidence of Coverage is amended to exclude a drug                     maximum of 8 doses in any 30-day period or up to 27
  that we have been covering and providing to you                       doses in any 100-day period.
  under this Membership Agreement and Evidence of
  Coverage, we will continue to provide the drug if a                   The pharmacy may reduce the day supply dispensed at
  prescription is required by law and a Plan Physician                  the Cost Sharing specified in this "Outpatient
  continues to prescribe the drug for the same condition                Prescription Drugs, Supplies, and Supplements" section
  and for a use approved by the federal Food and Drug                   to a 30-day supply in any 30-day period if the pharmacy
  Administration): 50% Coinsurance for up to a 30-                      determines that the item is in limited supply in the
  day supply in a 30-day period                                         market or for specific drugs (your Plan Pharmacy can tell
                                                                        you if a drug you take is one of these drugs).




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 33
About our drug formulary                                    Outpatient prescription drugs, supplies, and
Our drug formulary includes the list of drugs that have     supplements exclusions
been approved by our Pharmacy and Therapeutics              • Any requested packaging (such as dose packaging)
Committee for our Members. Our Pharmacy and                   other than the dispensing pharmacy's standard
Therapeutics Committee, which is primarily composed           packaging
of Plan Physicians, selects drugs for the drug formulary
based on a number of factors, including safety and          • Compounded products unless the drug is listed on our
effectiveness as determined from a review of medical          drug formulary or one of the ingredients requires a
literature. The Pharmacy and Therapeutics Committee           prescription by law
meets quarterly to consider additions and deletions based   • Drugs prescribed to shorten the duration of the
on new information or drugs that become available. If         common cold
you would like to request a copy of our drug formulary,
please call our Member Service Call Center. Note: The
presence of a drug on our drug formulary does not           Prosthetic and Orthotic Devices
necessarily mean that your Plan Physician will prescribe
it for a particular medical condition.                      We do not cover most prosthetic and orthotic devices,
                                                            but we do cover devices as described in this "Prosthetic
Our drug formulary guidelines allow you to obtain           and Orthotic Devices" section if all of the following
nonformulary prescription drugs (those not listed on our    requirements are met:
drug formulary for your condition) if they would            • The device is in general use, intended for repeated
otherwise be covered and a Plan Physician determines          use, and primarily and customarily used for medical
that they are Medically Necessary. If you disagree with       purposes
your Plan Physician's determination that a nonformulary     • The device is the standard device that adequately
prescription drug is not Medically Necessary, you may         meets your medical needs
file a grievance as described in the "Dispute Resolution"
section. Also, our formulary guidelines may require you     • You receive the device from the provider or vendor
to participate in a behavioral intervention program           that we select
approved by the Medical Group for specific conditions
and you may be required to pay for the program.             Coverage includes fitting and adjustment of these
                                                            devices, their repair or replacement (unless due to loss or
Services not covered under this "Outpatient                 misuse), and Services to determine whether you need a
Prescription Drugs, Supplies, and Supplements"              prosthetic or orthotic device. If we cover a replacement
section                                                     device, then you pay the Cost Sharing that you would
Coverage for the following Services is described under      pay for obtaining that device.
these headings in this "Benefits and Cost Sharing"
section:                                                    Internally implanted devices
                                                            We cover prosthetic and orthotic devices, such as
• Diabetes blood-testing equipment and their supplies,      pacemakers, intraocular lenses, cochlear implants,
  and insulin pumps and their supplies (refer to            osseointegrated hearing devices, and hip joints, if they
  "Durable Medical Equipment for Home Use")                 are implanted during a surgery that we are covering
• Durable medical equipment used to administer drugs        under another section of this "Benefits and Cost Sharing"
  (refer to "Durable Medical Equipment for Home             section. We cover these devices at no charge.
  Use")
                                                            External devices
• Outpatient administered drugs (refer to "Outpatient
                                                            We cover the following external prosthetic and orthotic
  Care")
                                                            devices at no charge:
• Drugs covered during a covered stay in a Plan
                                                            • Prosthetic devices and installation accessories to
  Hospital or Skilled Nursing Facility (refer to
                                                              restore a method of speaking following the removal
  "Hospital Inpatient Care" and "Skilled Nursing
                                                              of all or part of the larynx (this coverage does not
  Facility Care")
                                                              include electronic voice-producing machines, which
• Drugs prescribed for pain control and symptom               are not prosthetic devices)
  management of the terminal illness for Members who
                                                            • Prostheses needed after a Medically Necessary
  are receiving covered hospice care (refer to "Hospice
                                                              mastectomy, including custom-made prostheses when
  Care")
                                                              Medically Necessary and up to three brassieres
                                                              required to hold a prosthesis every 12 months



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 34
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Podiatric devices (including footwear) to prevent or                  • Outpatient surgery: a $100 Copayment per
  treat diabetes-related complications when prescribed                    procedure if it is provided in an outpatient or
  by a Plan Physician or by a Plan Provider who is a                      ambulatory surgery center or in a hospital operating
  podiatrist                                                              room, or if it is provided in any setting and a licensed
• Compression burn garments and lymphedema wraps                          staff member monitors your vital signs as you regain
  and garments                                                            sensation after receiving drugs to reduce sensation or
                                                                          to minimize discomfort. Any other outpatient surgery:
• Enteral formula for Members who require tube                            a $25 Copayment per procedure
  feeding in accord with Medicare guidelines
                                                                        • Hospital inpatient care (including room and
• Prostheses to replace all or part of an external facial                 board, drugs, and Plan Physician Services): a
  body part that has been removed or impaired as a                        $200 Copayment per day
  result of disease, injury, or congenital defect
                                                                        Services not covered under this "Reconstructive
Services not covered under this "Prosthetic and                         Surgery" section
Orthotic Devices" section                                               Coverage for the following Services is described under
Coverage for the following Services is described under                  these headings in this "Benefits and Cost Sharing"
these headings in this "Benefits and Cost Sharing"                      section:
section:
                                                                        • Dental and orthodontic Services that are an integral
• Contact lenses to treat aniridia or aphakia (refer to                   part of reconstructive surgery for cleft palate (refer to
  "Vision Services")                                                      "Dental and Orthodontic Services")

Prosthetic and orthotic devices exclusions                              • Outpatient imaging and laboratory (refer to
                                                                          "Outpatient Imaging, Laboratory, and Special
• Multifocal intraocular lenses and intraocular lenses to                 Procedures")
  correct astigmatism
                                                                        • Outpatient prescription drugs (refer to "Outpatient
• Except as otherwise described above in this                             Prescription Drugs, Supplies, and Supplements")
  "Prosthetic and Orthotic Devices" section, nonrigid
                                                                        • Outpatient administered drugs (refer to "Outpatient
  supplies, such as elastic stockings and wigs
                                                                          Care")
• Comfort, convenience, or luxury equipment or
                                                                        • Prosthetics and orthotics (refer to "Prosthetic and
  features
                                                                          Orthotic Devices")
• Shoes or arch supports, even if custom-made, except
  footwear described above in this "Prosthetic and                      Reconstructive surgery exclusions
  Orthotic Devices" section for diabetes-related
  complications                                                         • Surgery that, in the judgment of a Plan Physician
                                                                          specializing in reconstructive surgery, offers only a
                                                                          minimal improvement in appearance
Reconstructive Surgery                                                  • Surgery that is performed to alter or reshape normal
                                                                          structures of the body in order to improve appearance
We cover the following reconstructive surgery Services:
• Reconstructive surgery to correct or repair abnormal
  structures of the body caused by congenital defects,                 Services Associated with Clinical Trials
  developmental abnormalities, trauma, infection,
  tumors, or disease, if a Plan Physician determines that               We cover Services associated with cancer clinical trials
  it is necessary to improve function, or create a normal               if all of the following requirements are met:
  appearance, to the extent possible                                    • You are diagnosed with cancer
• Following Medically Necessary removal of all or part                  • You are accepted into a phase I, II, III, or IV clinical
  of a breast, we cover reconstruction of the breast,                     trial for cancer
  surgery and reconstruction of the other breast to                     • Your treating Plan Physician, or your treating Non–
  produce a symmetrical appearance, and treatment of                      Plan Physician if the Medical Group authorizes a
  physical complications, including lymphedemas                           written referral to the Non–Plan Physician for
                                                                          treatment of cancer (in accord with "Medical Group
You pay the following for covered reconstructive surgery                  authorization procedure for certain referrals" under
Services:                                                                 "Getting a Referral" in the "How to Obtain Services"
• Consultations and exams: a $25 Copayment per visit                      section), recommends participation in the clinical trial


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 35
   after determining that it has a meaningful potential to    • Drugs prescribed by a Plan Physician as part of your
   benefit you                                                  plan of care in the Plan Skilled Nursing Facility in
• The Services would be covered under this                      accord with our drug formulary guidelines if they are
  Membership Agreement and Evidence of Coverage                 administered to you in the Plan Skilled Nursing
  if they were not provided in connection with a clinical       Facility by medical personnel
  trial                                                       • Durable medical equipment in accord with our
• The clinical trial has a therapeutic intent, and its end      durable medical equipment formulary if Skilled
  points are not defined exclusively to test toxicity           Nursing Facilities ordinarily furnish the equipment

• The clinical trial involves a drug that is exempt under     • Imaging and laboratory Services that Skilled Nursing
  federal regulations from a new drug application, or           Facilities ordinarily provide
  the clinical trial is approved by: one of the National      • Medical social services
  Institutes of Health, the federal Food and Drug
                                                              • Blood, blood products, and their administration
  Administration (in the form of an investigational new
  drug application), the U.S. Department of Defense, or       • Medical supplies
  the U.S. Department of Veterans Affairs                     • Physical, occupational, and speech therapy
                                                              • Respiratory therapy
For covered Services related to a clinical trial, you will
pay the Cost Sharing you would pay if the Services
                                                              Services not covered under this "Skilled Nursing
were not related to a clinical trial.
                                                              Facility Care" section
Services associated with clinical trials                      Coverage for the following Services is described under
exclusions                                                    these headings in this "Benefits and Cost Sharing"
                                                              section:
• Services that are provided solely to satisfy data
  collection and analysis needs and are not used in your      • Outpatient imaging, laboratory, and special
  clinical management                                           procedures (refer to "Outpatient Imaging, Laboratory,
                                                                and Special Procedures")
• Services that are customarily provided by the research
  sponsors free of charge to enrollees in the clinical
  trial                                                       Transplant Services
                                                              We cover transplants of organs, tissue, or bone marrow
Skilled Nursing Facility Care                                 if the Medical Group provides a written referral for care
                                                              to a transplant facility as described in "Medical Group
Inside our Service Area, we cover at no charge up to          authorization procedure for certain referrals" under
100 days per benefit period (including any days we            "Getting a Referral" in the "How to Obtain Services"
covered under any other evidence of coverage) of skilled      section.
inpatient Services in a Plan Skilled Nursing Facility. The
skilled inpatient Services must be customarily provided       After the referral to a transplant facility, the following
by a Skilled Nursing Facility, and above the level of         applies:
custodial or intermediate care.
                                                              • If either the Medical Group or the referral facility
A benefit period begins on the date you are admitted to a       determines that you do not satisfy its respective
hospital or Skilled Nursing Facility at a skilled level of      criteria for a transplant, we will only cover Services
care. A benefit period ends on the date you have not been       you receive before that determination is made
an inpatient in a hospital or Skilled Nursing Facility,       • Health Plan, Plan Hospitals, the Medical Group, and
receiving a skilled level of care, for 60 consecutive days.     Plan Physicians are not responsible for finding,
A new benefit period can begin only after any existing          furnishing, or ensuring the availability of an organ,
benefit period ends. A prior three-day stay in an acute         tissue, or bone marrow donor
care hospital is not required.                                • In accord with our guidelines for Services for living
                                                                transplant donors, we provide certain donation-related
We cover the following Services:                                Services for a donor, or an individual identified by
• Physician and nursing Services                                the Medical Group as a potential donor, whether or
                                                                not the donor is a Member. These Services must be
• Room and board
                                                                directly related to a covered transplant for you, which
                                                                may include certain Services for harvesting the organ,


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                         Page 36
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   tissue, or bone marrow and for treatment of                          • Services for the purpose of correcting refractive
   complications. Our guidelines for donor Services are                   defects such as myopia, hyperopia, or astigmatism
   available by calling our Member Service Call Center
                                                                        • Eyeglass lenses and frames
For covered transplant Services that you receive, you                   • Contact lenses, including fitting and dispensing
will pay the Cost Sharing you would pay if the                            (except for contact lenses to treat aphakia or aniridia
Services were not related to a transplant.                                as described under this "Vision Services" section)
                                                                        • Eye exams for the purpose of obtaining or
We provide or pay for donation-related Services for                       maintaining contact lenses
actual or potential donors (whether or not they are
                                                                        • Low vision devices
Members) in accord with our guidelines for donor
Services at no charge.

Services not covered under this "Transplant                            Exclusions, Limitations,
Services" section
                                                                       Coordination of Benefits, and
Coverage for the following Services is described under
these headings in this "Benefits and Cost Sharing"                     Reductions
section:
• Outpatient imaging and laboratory (refer to                          Exclusions
  "Outpatient Imaging, Laboratory, and Special
  Procedures")                                                          The items and services listed in this "Exclusions" section
                                                                        are excluded from coverage. These exclusions apply to
• Outpatient prescription drugs (refer to "Outpatient
                                                                        all Services that would otherwise be covered under this
  Prescription Drugs, Supplies, and Supplements")
                                                                        Membership Agreement and Evidence of Coverage
• Outpatient administered drugs (refer to "Outpatient                   regardless of whether the services are within the scope of
  Care")                                                                a provider's license or certificate. Additional exclusions
                                                                        that apply only to a particular benefit are listed in the
                                                                        description of that benefit in the "Benefits and Cost
Vision Services                                                         Sharing" section.
We cover the following:
                                                                        Acupuncture Services
• Routine preventive vision screenings: no charge                       Acupuncture Services and the Services of an
• Eye exams for refraction to determine the need for                    acupuncturist except for Services covered under
  vision correction and to provide a prescription for                   "Outpatient Care" in the "Benefits and Cost Sharing"
  eyeglass lenses: no charge                                            section.
• Up to two Medically Necessary contact lenses, fitting,
                                                                        Artificial insemination and conception by
  and dispensing per eye every 12 months (including
                                                                        artificial means
  lenses we covered under any other evidence of
  coverage) to treat aniridia (missing iris): no charge                 All Services related to artificial insemination and
                                                                        conception by artificial means, such as: ovum
• Up to six Medically Necessary aphakic contact                         transplants, gamete intrafallopian transfer (GIFT), semen
  lenses, fitting, and dispensing per eye per calendar                  and eggs (and Services related to their procurement and
  year (including lenses we covered under any other                     storage), in vitro fertilization (IVF), and zygote
  evidence of coverage) to treat aphakia (absence of the                intrafallopian transfer (ZIFT).
  crystalline lens of the eye) for Members through age
  9: no charge                                                          Certain exams and Services
                                                                        Physical exams and other Services (1) required for
Services not covered under this "Vision
                                                                        obtaining or maintaining employment or participation in
Services" section
                                                                        employee programs, (2) required for insurance or
• Services related to the eye or vision other than                      licensing, or (3) on court order or required for parole or
  Services covered under this "Vision Services" section                 probation. This exclusion does not apply if a Plan
                                                                        Physician determines that the Services are Medically
Vision Services exclusions                                              Necessary.
• Industrial frames



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 37
Chiropractic Services                                        Experimental or investigational Services
Chiropractic Services and the Services of a chiropractor.    A Service is experimental or investigational if we, in
                                                             consultation with the Medical Group, determine that one
Cosmetic Services                                            of the following is true:
Services that are intended primarily to change or            • Generally accepted medical standards do not
maintain your appearance, except that this exclusion           recognize it as safe and effective for treating the
does not apply to any of the following:                        condition in question (even if it has been authorized
• Services covered under "Reconstructive Surgery" in           by law for use in testing or other studies on human
  the "Benefits and Cost Sharing" section                      patients)
• The following devices covered under "Prosthetic and        • It requires government approval that has not been
  Orthotic Devices" in the "Benefits and Cost Sharing"         obtained when the Service is to be provided
  section: testicular implants implanted as part of a
  covered reconstructive surgery, breast prostheses          This exclusion does not apply to any of the following:
  needed after a mastectomy and prostheses to replace        • Experimental or investigational Services when an
  all or part of an external facial body part                  investigational application has been filed with the
                                                               federal Food and Drug Administration (FDA) and the
Custodial care                                                 manufacturer or other source makes the Services
Assistance with activities of daily living (for example:       available to you or Kaiser Permanente through an
walking, getting in and out of bed, bathing, dressing,         FDA-authorized procedure, except that we do not
feeding, toileting, and taking medicine).                      cover Services that are customarily provided by
                                                               research sponsors free of charge to enrollees in a
This exclusion does not apply to assistance with               clinical trial or other investigational treatment
activities of daily living that is provided as part of         protocol
covered hospice, Skilled Nursing Facility, or inpatient
                                                             • Services covered under "Services Associated with
hospital care.
                                                               Clinical Trials" in the "Benefits and Cost Sharing"
                                                               section
Dental and orthodontic Services
Dental and orthodontic Services such as X-rays,              Please refer to the "Dispute Resolution" section for
appliances, implants, Services provided by dentists or       information about Independent Medical Review related
orthodontists, dental Services following accidental injury   to denied requests for experimental or investigational
to teeth, and dental Services resulting from medical         Services.
treatment such as surgery on the jawbone and radiation
treatment.                                                   Hair loss or growth treatment
                                                             Items and services for the promotion, prevention, or
This exclusion does not apply to Services covered under
                                                             other treatment of hair loss or hair growth.
"Dental and Orthodontic Services" in the "Benefits and
Cost Sharing" section.
                                                             Infertility Services
Disposable supplies                                          Services related to the diagnosis and treatment of
                                                             infertility.
Disposable supplies for home use, such as bandages,
gauze, tape, antiseptics, dressings, Ace-type bandages,
                                                             Intermediate care
and diapers, underpads, and other incontinence supplies.
                                                             Care in a licensed intermediate care facility. This
                                                             exclusion does not apply to Services covered under
This exclusion does not apply to disposable supplies
                                                             "Durable Medical Equipment," "Home Health Care," and
covered under "Durable Medical Equipment for Home
                                                             "Hospice Care" in the "Benefits and Cost Sharing"
Use," "Home Health Care," "Hospice Care," "Ostomy
                                                             section.
and Urological Supplies," and "Outpatient Prescription
Drugs, Supplies, and Supplements" in the "Benefits and
                                                             Items and services that are not health care items
Cost Sharing" section.
                                                             and services
                                                             For example, we do not cover:
                                                             • Teaching manners and etiquette




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 38
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Teaching and support services to develop planning                     Routine foot care items and services
  skills such as daily activity planning and project or                 Routine foot care items and services that are not
  task planning                                                         Medically Necessary.
• Items and services that increase academic knowledge
  or skills                                                             Services not approved by the federal Food and
                                                                        Drug Administration
• Teaching and support services to increase intelligence
                                                                        Drugs, supplements, tests, vaccines, devices, radioactive
• Academic coaching or tutoring for skills such as                      materials, and any other Services that by law require
  grammar, math, and time management                                    federal Food and Drug Administration (FDA) approval
• Teaching you how to read, whether or not you have                     in order to be sold in the U.S. but are not approved by the
  dyslexia                                                              FDA. This exclusion applies to Services provided
                                                                        anywhere, even outside the U.S.
• Educational testing
• Teaching art, dance, horse riding, music, play or                     This exclusion does not apply to any of the following:
  swimming                                                              • Services covered under the "Emergency Services and
• Teaching skills for employment or vocational                            Urgent Care" section that you receive outside the U.S.
  purposes                                                              • Experimental or investigational Services when an
• Vocational training or teaching vocational skills                       investigational application has been filed with the
• Professional growth courses                                             FDA and the manufacturer or other source makes the
                                                                          Services available to you or Kaiser Permanente
• Training for a specific job or employment counseling                    through an FDA-authorized procedure, except that we
• Aquatic therapy and other water therapy                                 do not cover Services that are customarily provided
                                                                          by research sponsors free of charge to enrollees in a
Massage therapy                                                           clinical trial or other investigational treatment
                                                                          protocol
Oral nutrition                                                          • Services covered under "Services Associated with
Outpatient oral nutrition, such as dietary supplements,                   Clinical Trials" in the "Benefits and Cost Sharing"
herbal supplements, weight loss aids, formulas, and food.                 section

This exclusion does not apply to any of the following:                  Please refer to the "Dispute Resolution" section for
• Amino acid–modified products and elemental dietary                    information about Independent Medical Review related
  enteral formula covered under "Outpatient                             to denied requests for experimental or investigational
  Prescription Drugs, Supplies, and Supplements" in                     Services.
  the "Benefits and Cost Sharing" section
                                                                        Services performed by unlicensed people
• Enteral formula covered under "Prosthetic and                         Services that are performed safely and effectively by
  Orthotic Devices" in the "Benefits and Cost Sharing"                  people who do not require licenses or certificates by the
  section                                                               state to provide health care services and where the
                                                                        Member's condition does not require that the services be
Residential care                                                        provided by a licensed health care provider.
Care in a facility where you stay overnight, except that
this exclusion does not apply when the overnight stay is                Services related to a noncovered Service
part of covered care in a hospital, a Skilled Nursing                   When a Service is not covered, all Services related to the
Facility, inpatient respite care covered in the "Hospice                noncovered Service are excluded, except for Services we
Care" section, a licensed facility providing crisis                     would otherwise cover to treat complications of the
residential Services covered under "Inpatient psychiatric               noncovered Service. For example, if you have a
hospitalization and intensive psychiatric treatment                     noncovered cosmetic surgery, we would not cover
programs" in the "Mental Health Services" section, or a                 Services you receive in preparation for the surgery or for
licensed facility providing transitional residential                    follow-up care. If you later suffer a life-threatening
recovery Services covered under the "Chemical                           complication such as a serious infection, this exclusion
Dependency Services" section.                                           would not apply and we would cover any Services that
                                                                        we would otherwise cover to treat that complication.




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 39
Surrogacy                                                      Coordination of Benefits
Services for anyone in connection with a surrogacy
arrangement, except for otherwise-covered Services             If you have Medicare coverage, we will coordinate
provided to a Member who is a surrogate. A surrogacy           benefits with your Medicare coverage under Medicare
arrangement is one in which a woman (the surrogate)            rules. Medicare rules determine which coverage pays
agrees to become pregnant and to surrender the baby to         first, or is "primary," and which coverage pays second, or
another person or persons who intend to raise the child.       is "secondary." You must give us any information we
Please refer to "Surrogacy arrangements" under                 request to help us coordinate benefits. Please call our
"Reductions" in this "Exclusions, Limitations,                 Member Service Call Center to find out which Medicare
Coordination of Benefits, and Reductions" section for          rules apply to your situation, and how payment will be
information about your obligations to us in connection         handled.
with a surrogacy arrangement, including your obligation
to reimburse us for any Services we cover.
                                                               Reductions
Transgender surgery                                            Employer responsibility
                                                               For any Services that the law requires an employer to
Travel and lodging expenses                                    provide, we will not pay the employer, and when we
Travel and lodging expenses, except that in some               cover any such Services we may recover the value of the
situations if the Medical Group refers you to a Non–Plan       Services from the employer.
Provider as described in "Medical Group authorization
procedure for certain referrals" under "Getting a              Government agency responsibility
Referral" in the "How to Obtain Services" section, we          For any Services that the law requires be provided only
may pay certain expenses that we preauthorize in accord        by or received only from a government agency, we will
with our travel and lodging guidelines. Our travel and         not pay the government agency, and when we cover any
lodging guidelines are available from our Member               such Services we may recover the value of the Services
Service Call Center.                                           from the government agency.

This exclusion does not apply to reimbursement for             Injuries or illnesses alleged to be caused by
travel and lodging expenses provided under "Bariatric          third parties
Surgery" in the "Benefits and Cost Sharing" section.
                                                               If you obtain a judgment or settlement from or on behalf
                                                               of a third party who allegedly caused an injury or illness
Limitations                                                    for which you received covered Services, you must pay
                                                               us Charges for those Services, except that the amount
We will make a good faith effort to provide or arrange         you must pay will not exceed the maximum amount
for covered Services within the remaining availability of      allowed under California Civil Code Section 3040. Note:
facilities or personnel in the event of unusual                This "Injuries or illnesses alleged to be caused by third
circumstances that delay or render impractical the             parties" section does not affect your obligation to pay
provision of Services under this Membership Agreement          Cost Sharing for these Services, but we will credit any
and Evidence of Coverage, such as major disaster,              such payments toward the amount you must pay us under
epidemic, war, riot, civil insurrection, disability of a       this paragraph.
large share of personnel at a Plan Facility, complete or
partial destruction of facilities, and labor disputes. Under   To the extent permitted or required by law, we have the
these circumstances, if you have an Emergency Medical          option of becoming subrogated to all claims, causes of
Condition, call 911 or go to the nearest hospital as           action, and other rights you may have against a third
described under "Emergency Services" in the                    party or an insurer, government program, or other source
"Emergency Services and Urgent Care" section, and we           of coverage for monetary damages, compensation, or
will provide coverage and reimbursement as described in        indemnification on account of the injury or illness
that section.                                                  allegedly caused by the third party. We will be so
                                                               subrogated as of the time we mail or deliver a written
Additional limitations that apply only to a particular         notice of our exercise of this option to you or your
benefit are listed in the description of that benefit in the   attorney, but we will be subrogated only to the extent of
"Benefits and Cost Sharing" section.                           the total of Charges for the relevant Services.

                                                               To secure our rights, we will have a lien on the proceeds
                                                               of any judgment or settlement you or we obtain against a


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                       Page 40
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
third party. The proceeds of any judgment or settlement                 Medicare benefits
that you or we obtain shall first be applied to satisfy our             Your benefits are reduced by any benefits you have
lien, regardless of whether the total amount of the                     under Medicare except for Members whose Medicare
proceeds is less than the actual losses and damages you                 benefits are secondary by law.
incurred.
                                                                        Surrogacy arrangements
Within 30 days after submitting or filing a claim or legal              If you enter into a surrogacy arrangement, you must pay
action against a third party, you must send written notice              us Charges for covered Services you receive related to
of the claim or legal action to:                                        conception, pregnancy, or delivery in connection with
     Southern California Third Party Liability Supervisor               that arrangement ("Surrogacy Health Services"), except
     Kaiser Foundation Health Plan, Inc.                                that the amount you must pay will not exceed the
     Special Recovery Unit                                              compensation you are entitled to receive under the
     Parsons East, Second Floor                                         surrogacy arrangement. A surrogacy arrangement is one
     393 E. Walnut St.                                                  in which a woman agrees to become pregnant and to
     Pasadena, CA 91188                                                 surrender the baby to another person or persons who
                                                                        intend to raise the child. Note: This "Surrogacy
In order for us to determine the existence of any rights                arrangements" section does not affect your obligation to
we may have and to satisfy those rights, you must                       pay Cost Sharing for these Services, but we will credit
complete and send us all consents, releases,                            any such payments toward the amount you must pay us
authorizations, assignments, and other documents,                       under this paragraph.
including lien forms directing your attorney, the third
party, and the third party's liability insurer to pay us                By accepting Surrogacy Health Services, you
directly. You may not agree to waive, release, or reduce                automatically assign to us your right to receive payments
our rights under this provision without our prior, written              that are payable to you or your chosen payee under the
consent.                                                                surrogacy arrangement, regardless of whether those
                                                                        payments are characterized as being for medical
If your estate, parent, guardian, or conservator asserts a              expenses. To secure our rights, we will also have a lien
claim against a third party based on your injury or                     on those payments. Those payments shall first be applied
illness, your estate, parent, guardian, or conservator and              to satisfy our lien. The assignment and our lien will not
any settlement or judgment recovered by the estate,                     exceed the total amount of your obligation to us under
parent, guardian, or conservator shall be subject to our                the preceding paragraph.
liens and other rights to the same extent as if you had
asserted the claim against the third party. We may assign               Within 30 days after entering into a surrogacy
our rights to enforce our liens and other rights.                       arrangement, you must send written notice of the
                                                                        arrangement, including the names and addresses of the
If you have Medicare, Medicare law may apply with                       other parties to the arrangement, and a copy of any
respect to Services covered by Medicare.                                contracts or other documents explaining the arrangement,
                                                                        to:
Some providers have contracted with Kaiser Permanente                        Surrogacy Third Party Liability Supervisor
to provide certain Services to Members at rates that are                     Kaiser Foundation Health Plan, Inc.
typically less than the fees that the providers ordinarily                   Special Recovery Unit
charge to the general public ("General Fees"). However,                      Parsons East, Second Floor
these contracts may allow the providers to recover all or                    393 E. Walnut St.
a portion of the difference between the fees paid by                         Pasadena, CA 91188
Kaiser Permanente and their General Fees by means of a
lien claim under California Civil Code Sections 3045.1–                 You must complete and send us all consents, releases,
3045.6 against a judgment or settlement that you receive                authorizations, lien forms, and other documents that are
from or on behalf of a third party. For Services the                    reasonably necessary for us to determine the existence of
provider furnished, our recovery and the provider's                     any rights we may have under this "Surrogacy
recovery together will not exceed the provider's General                arrangements" section and to satisfy those rights. You
Fees.                                                                   may not agree to waive, release, or reduce our rights
                                                                        under this provision without our prior, written consent.

                                                                        If your estate, parent, guardian, or conservator asserts a
                                                                        claim against a third party based on the surrogacy



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 41
arrangement, your estate, parent, guardian, or                • A Plan Physician has said that Services are not
conservator and any settlement or judgment recovered by         Medically Necessary and you want us to cover the
the estate, parent, guardian, or conservator shall be           Services
subject to our liens and other rights to the same extent as
                                                              • You were told that Services are not covered and you
if you had asserted the claim against the third party. We
                                                                believe that the Services should be covered
may assign our rights to enforce our liens and other
rights.                                                       • You received care from a Non–Plan Provider that we
                                                                did not authorize (other than Emergency Services,
U.S. Department of Veterans Affairs                             Post-Stabilization Care, Out-of-Area Urgent Care, or
For any Services for conditions arising from military           emergency ambulance Services) and you want us to
service that the law requires the Department of Veterans        pay for the care
Affairs to provide, we will not pay the Department of         • We did not decide fully in your favor on a claim for
Veterans Affairs, and when we cover any such Services           Services described in the "Emergency Services and
we may recover the value of the Services from the               Urgent Care" section or under "Ambulance Services"
Department of Veterans Affairs.                                 in the "Benefits and Cost Sharing" section and you
                                                                want to appeal our decision
Workers' compensation or employer's liability
                                                              • You are dissatisfied with how long it took to get
benefits
                                                                Services, including getting an appointment, in the
You may be eligible for payments or other benefits,             waiting room, or in the exam room
including amounts received as a settlement (collectively
referred to as "Financial Benefit"), under workers'           • You want to report unsatisfactory behavior by
compensation or employer's liability law. We will               providers or staff, or dissatisfaction with the
provide covered Services even if it is unclear whether          condition of a facility
you are entitled to a Financial Benefit, but we may           • Your membership was terminated retroactively for a
recover the value of any covered Services from the              reason other than nonpayment of Premiums or
following sources:                                              contributions toward the cost of coverage
• From any source providing a Financial Benefit or            • We denied your membership application
  from whom a Financial Benefit is due
• From you, to the extent that a Financial Benefit is         Your grievance must explain your issue, such as the
  provided or payable or would have been required to          reasons why you believe a decision was in error or why
  be provided or payable if you had diligently sought to      you are dissatisfied about Services you received. You
  establish your rights to the Financial Benefit under        must submit your grievance orally or in writing within
  any workers' compensation or employer's liability law       180 days of the date of the incident that caused your
                                                              dissatisfaction as follows:
                                                              • If we did not decide fully in your favor on a claim for
Dispute Resolution                                              Services described in the "Emergency Services and
                                                                Urgent Care" section or under "Ambulance Services"
                                                                in the "Benefits and Cost Sharing" section and you
Grievances                                                      want to appeal our decision, you can submit your
                                                                grievance in one of the following ways:
We are committed to providing you with quality care and         ♦ to the Claims Department at the following address:
with a timely response to your concerns. You can discuss              Kaiser Foundation Health Plan, Inc.
your concerns with our Member Services representatives                Special Services Unit
at most Plan Facilities, or you can call our Member
                                                                      P.O. Box 7136
Service Call Center.
                                                                      Pasadena, CA 91109
                                                                 ♦ by calling our Member Service Call Center at
You can file a grievance for any issue. Here are some
examples of reasons you might file a grievance:                     1-800-464-4000 or 1-800-390-3510 (TTY users
                                                                    call 1-800-777-1370)
• You are not satisfied with the quality of care you
  received                                                    • For all other issues, you can submit your grievance in
                                                                one of the following ways:
• You received a written denial of Services that require
                                                                 ♦ to the Member Services Department at a Plan
  prior authorization from the Medical Group or a
                                                                    Facility (please refer to Your Guidebook for
  "Notice of Non-Coverage" and you want us to cover
                                                                    addresses)
  the Services


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                     Page 42
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   ♦ by calling our Member Service Call Center at                       grievance, we will send you a written decision that tells
       1-800-464-4000 (TTY users call 1-800-777-1370)                   you the reasons and about additional dispute resolution
   ♦ through our website at kp.org                                      options.

We will send you a confirmation letter within five days                 Note: If you have an issue that involves an imminent and
after we receive your grievance. We will send you our                   serious threat to your health (such as severe pain or
written decision within 30 days after we receive your                   potential loss of life, limb, or major bodily function), you
grievance. If we do not approve your request, we will tell              can contact the California Department of Managed
you the reasons and about additional dispute resolution                 Health Care directly at any time at 1-888-HMO-2219
options. Note: If we resolve your issue to your                         (TDD 1-877-688-9891) without first filing a grievance
satisfaction by the end of the next business day after we               with us.
receive your grievance orally, by fax, or through our
website, and a Member Services representative notifies
you orally about our decision, we will not send you a
                                                                       Supporting Documents
confirmation letter or a written decision unless your                   It is helpful for you to include any information that
grievance involves a coverage dispute, a dispute about                  clarifies or supports your position. You may want to
whether a Service is Medically Necessary, or an                         included supporting information with your grievance,
experimental or investigational treatment.                              such as medical records or physician opinions. When
                                                                        appropriate, we will request medical records from Plan
Expedited grievance                                                     Providers on your behalf. If you have consulted with a
You or your physician may make an oral or written                       Non–Plan Provider and are unable to provide copies of
request that we expedite our decision about your                        relevant medical records, we will contact the provider to
grievance if it involves an imminent and serious threat to              request a copy of your medical records. We will ask you
your health, such as severe pain or potential loss of life,             to send or fax us a written authorization so that we can
limb, or major bodily function. We will inform you of                   request your records. If we do not receive the
our decision within 72 hours (orally or in writing).                    information we request in a timely fashion, we will make
                                                                        a decision based on the information we have.
If the request is for a continuation of an expiring course
of treatment and you make the request at least 24 hours
before the treatment expires, we will inform you of our                Who May File
decision within 24 hours.
                                                                        The following persons may file a grievance:
You or your physician must request an expedited                         • You may file for yourself
decision in one of the following ways and you must
                                                                        • You may appoint someone as your authorized
specifically state that you want an expedited decision:
                                                                          representative by completing our authorization form.
• Call our Expedited Review Unit toll free at                             Authorization forms are available from your local
  1-888-987-7247 (TTY users call 1-800-777-1370),                         Member Services Department at a Plan Facility or by
  which is available Monday through Saturday from                         calling our Member Service Call Center. Your
  8:30 a.m. to 5 p.m. After hours, you may leave a                        completed authorization form must accompany the
  message and a representative will return your call the                  grievance
  next business day
                                                                        • You may file for your Dependent under age 18,
• Send your written request to:                                           except that he or she must appoint you as his or her
   Kaiser Foundation Health Plan, Inc.                                    authorized representative if he or she has the legal
   Expedited Review Unit                                                  right to control release of information that is relevant
   P.O. Box 23170                                                         to the grievance
   Oakland, CA 94623-0170                                               • You may file for your ward if you are a court-
• Fax your written request to our Expedited Review                        appointed guardian, except that he or she must
  Unit toll free at 1-888-987-2252                                        appoint you as his or her authorized representative if
                                                                          he or she has the legal right to control release of
• Deliver your request in person to your local Member
                                                                          information that is relevant to the grievance
  Services Department at a Plan Facility
                                                                        • You may file for your conservatee if you are a court-
If we do not approve your request for an expedited                        appointed conservator
decision, we will notify you and we will respond to your
grievance within 30 days. If we do not approve your


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 43
• You may file for your principal if you are an agent       You may qualify for IMR if all of the following are true:
  under a currently effective health care proxy, to the     • One of these situations applies to you:
  extent provided under state law
                                                               ♦ you have a recommendation from a provider
• Your physician may request an expedited grievance               requesting Medically Necessary Services
  as described under "Expedited grievance" in this
                                                               ♦ you have received Emergency Services,
  "Dispute Resolution" section
                                                                  emergency ambulance Services, or Urgent Care
                                                                  from a provider who determined the Services to be
Department of Managed Health Care                                 Medically Necessary
Complaints                                                     ♦ you have been seen by a Plan Provider for the
                                                                  diagnosis or treatment of your medical condition
The California Department of Managed Health Care            • Your request for payment or Services has been
is responsible for regulating health care service             denied, modified, or delayed based in whole or in part
plans. If you have a grievance against your health            on a decision that the Services are not Medically
plan, you should first telephone your health plan toll        Necessary
free at 1-800-464-4000 (TTY users call
                                                            • You have filed a grievance and we have denied it or
1-800-777-1370) and use your health plan's grievance          we haven't made a decision about your grievance
process before contacting the department. Utilizing this      within 30 days (or three days for expedited
grievance procedure does not prohibit any potential legal     grievances). The Department of Managed Health
rights or remedies that may be available to you. If you       Care may waive the requirement that you first file a
need help with a grievance involving an emergency, a          grievance with us in extraordinary and compelling
grievance that has not been satisfactorily resolved by        cases, such as severe pain or potential loss of life,
your health plan, or a grievance that has remained            limb, or major bodily function
unresolved for more than 30 days, you may call the
department for assistance. You may also be eligible for     You may also qualify for IMR if the Service you
an Independent Medical Review (IMR). If you are             requested has been denied on the basis that it is
eligible for IMR, the IMR process will provide an           experimental or investigational as described under
impartial review of medical decisions made by a health      "Experimental or investigational denials."
plan related to the medical necessity of a proposed
service or treatment, coverage decisions for treatments
                                                            If the Department of Managed Health Care determines
that are experimental or investigational in nature and
                                                            that your case is eligible for IMR, it will ask us to send
payment disputes for emergency or urgent medical
                                                            your case to the Department of Managed Health Care's
services. The department also has a toll-free telephone
                                                            Independent Medical Review organization. The
number (1-888-HMO-2219) and a TDD line                      Department of Managed Health Care will promptly
(1-877-688-9891) for the hearing and speech                 notify you of its decision after it receives the
impaired. The department's Internet website                 Independent Medical Review organization's
http://www.hmohelp.ca.gov has complaint forms,              determination. If the decision is in your favor, we will
IMR application forms and instructions online.              contact you to arrange for the Service or payment.

                                                            Experimental or investigational denials
Independent Medical Review (IMR)                            If we deny a Service because it is experimental or
                                                            investigational, we will send you our written explanation
If you qualify, you or your authorized representative may   within five days of making our decision. We will explain
have your issue reviewed through the Independent            why we denied the Service and provide additional
Medical Review (IMR) process managed by the                 dispute resolution options. Also, we will provide
California Department of Managed Health Care. The           information about your right to request Independent
Department of Managed Health Care determines which          Medical Review if we had the following information
cases qualify for IMR. This review is at no cost to you.    when we made our decision:
If you decide not to request an IMR, you may give up the
right to pursue some legal actions against us.              • Your treating physician provided us a written
                                                              statement that you have a life-threatening or seriously
                                                              debilitating condition and that standard therapies have
                                                              not been effective in improving your condition, or
                                                              that standard therapies would not be appropriate, or
                                                              that there is no more beneficial standard therapy we



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 44
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   cover than the therapy being requested. "Life-                          Kaiser Foundation Health Plan, Inc. (Health Plan),
   threatening" means diseases or conditions where the                     including any claim for medical or hospital
   likelihood of death is high unless the course of the                    malpractice (a claim that medical services were
   disease is interrupted, or diseases or conditions with                  unnecessary or unauthorized or were improperly,
   potentially fatal outcomes where the end point of                       negligently, or incompetently rendered), for premises
   clinical intervention is survival. "Seriously                           liability, or relating to the coverage for, or delivery
   debilitating" means diseases or conditions that cause                   of, Services, irrespective of the legal theories upon
   major irreversible morbidity                                            which the claim is asserted
• If your treating physician is a Plan Physician, he or                 • The claim is asserted by one or more Member Parties
  she recommended a treatment, drug, device,                              against one or more Kaiser Permanente Parties or by
  procedure, or other therapy and certified that the                      one or more Kaiser Permanente Parties against one or
  requested therapy is likely to be more beneficial to                    more Member Parties
  you than any available standard therapies and                         • The claim is not within the jurisdiction of the Small
  included a statement of the evidence relied upon by                     Claims Court
  the Plan Physician in certifying his or her
  recommendation                                                        • If coverage under this Membership Agreement and
                                                                          Evidence of Coverage is subject to the Employee
• You (or your Non–Plan Physician who is a licensed,                      Retirement Income Security Act (ERISA) claims
  and either a board-certified or board-eligible,                         procedure regulation (29 CFR 2560.503-1), the claim
  physician qualified in the area of practice appropriate                 is not about an "adverse benefit determination" as
  to treat your condition) requested a therapy that,                      defined in that regulation. Note: Claims about
  based on two documents from the medical and                             "adverse benefit determinations" are excluded from
  scientific evidence, as defined in California Health                    this binding arbitration requirement only until such
  and Safety Code Section 1370.4(d), is likely to be                      time as the regulation prohibiting mandatory binding
  more beneficial for you than any available standard                     arbitration of this category of claim (29 CFR
  therapy. The physician's certification included a                       2560.503-1(c)(4)) is modified, amended, repealed,
  statement of the evidence relied upon by the                            superseded, or otherwise found to be invalid. If this
  physician in certifying his or her recommendation.                      occurs, these claims will automatically become
  We do not cover the Services of the Non–Plan                            subject to mandatory binding arbitration without
  Provider                                                                further notice

Note: You can request IMR for experimental or                           As referred to in this "Binding Arbitration" section,
investigational denials at any time without first filing a              "Member Parties" include:
grievance with us.
                                                                        • A Member
                                                                        • A Member's heir, relative, or personal representative
Binding Arbitration
                                                                        • Any person claiming that a duty to him or her arises
For all claims subject to this "Binding Arbitration"                      from a Member's relationship to one or more Kaiser
section, both Claimants and Respondents give up the                       Permanente Parties
right to a jury or court trial and accept the use of binding
arbitration. Insofar as this "Binding Arbitration" section              "Kaiser Permanente Parties" include:
applies to claims asserted by Kaiser Permanente Parties,
                                                                        • Kaiser Foundation Health Plan, Inc.
it shall apply retroactively to all unresolved claims that
accrued before the effective date of this Membership                    • Kaiser Foundation Hospitals
Agreement and Evidence of Coverage. Such retroactive                    • KP Cal, LLC
application shall be binding only on the Kaiser
Permanente Parties.                                                     • The Permanente Medical Group, Inc.
                                                                        • Southern California Permanente Medical Group
Scope of arbitration                                                    • The Permanente Federation, LLC
Any dispute shall be submitted to binding arbitration
if all of the following requirements are met:                           • The Permanente Company, LLC

• The claim arises from or is related to an alleged                     • Any Kaiser Foundation Hospitals, The Permanente
  violation of any duty incident to or arising out of or                  Medical Group, Inc., or Southern California
  relating to this Membership Agreement and Evidence                      Permanente Medical Group physician
  of Coverage or a Member Party's relationship to


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 45
• Any individual or organization whose contract with         simultaneously serve it upon the Respondents. The Fee
  any of the organizations identified above requires         Waiver Form sets forth the criteria for waiving fees and
  arbitration of claims brought by one or more Member        is available by calling our Member Service Call Center.
  Parties
                                                             Number of arbitrators
• Any employee or agent of any of the foregoing
                                                             The number of arbitrators may affect the Claimant's
"Claimant" refers to a Member Party or a Kaiser              responsibility for paying the neutral arbitrator's fees and
Permanente Party who asserts a claim as described            expenses.
above. "Respondent" refers to a Member Party or a
Kaiser Permanente Party against whom a claim is              If the Demand for Arbitration seeks total damages of
asserted.                                                    $200,000 or less, the dispute shall be heard and
                                                             determined by one neutral arbitrator, unless the parties
Initiating arbitration                                       otherwise agree in writing that the arbitration shall be
                                                             heard by two party arbitrators and one neutral arbitrator.
Claimants shall initiate arbitration by serving a Demand
                                                             The neutral arbitrator shall not have authority to award
for Arbitration. The Demand for Arbitration shall include
                                                             monetary damages that are greater than $200,000.
the basis of the claim against the Respondents; the
amount of damages the Claimants seek in the arbitration;
the names, addresses, and telephone numbers of the           If the Demand for Arbitration seeks total damages of
Claimants and their attorney, if any; and the names of all   more than $200,000, the dispute shall be heard and
Respondents. Claimants shall include all claims against      determined by one neutral arbitrator and two party
Respondents that are based on the same incident,             arbitrators, one jointly appointed by all Claimants and
transaction, or related circumstances in the Demand for      one jointly appointed by all Respondents. Parties who are
Arbitration.                                                 entitled to select a party arbitrator may agree to waive
                                                             this right. If all parties agree, these arbitrations will be
Serving Demand for Arbitration                               heard by a single neutral arbitrator.
Health Plan, Kaiser Foundation Hospitals, KP Cal, LLC,
                                                             Payment of arbitrators' fees and expenses
The Permanente Medical Group, Inc., Southern
California Permanente Medical Group, The Permanente          Health Plan will pay the fees and expenses of the neutral
Federation, LLC, and The Permanente Company, LLC,            arbitrator under certain conditions as set forth in the
shall be served with a Demand for Arbitration by mailing     Rules for Kaiser Permanente Member Arbitrations
the Demand for Arbitration addressed to that Respondent      Overseen by the Office of the Independent Administrator
in care of:                                                  ("Rules of Procedure"). In all other arbitrations, the fees
                                                             and expenses of the neutral arbitrator shall be paid one-
     Kaiser Foundation Health Plan, Inc.
                                                             half by the Claimants and one-half by the Respondents.
     Legal Department
     393 E. Walnut St.
                                                             If the parties select party arbitrators, Claimants shall be
     Pasadena, CA 91188
                                                             responsible for paying the fees and expenses of their
                                                             party arbitrator and Respondents shall be responsible for
Service on that Respondent shall be deemed completed
                                                             paying the fees and expenses of their party arbitrator.
when received. All other Respondents, including
individuals, must be served as required by the California
                                                             Costs
Code of Civil Procedure for a civil action.
                                                             Except for the aforementioned fees and expenses of the
Filing fee                                                   neutral arbitrator, and except as otherwise mandated by
                                                             laws that apply to arbitrations under this "Binding
The Claimants shall pay a single, nonrefundable filing
                                                             Arbitration" section, each party shall bear the party's own
fee of $150 per arbitration payable to "Arbitration
                                                             attorneys' fees, witness fees, and other expenses incurred
Account" regardless of the number of claims asserted in
                                                             in prosecuting or defending against a claim regardless of
the Demand for Arbitration or the number of Claimants
                                                             the nature of the claim or outcome of the arbitration.
or Respondents named in the Demand for Arbitration.
                                                             Rules of Procedure
Any Claimant who claims extreme hardship may request
                                                             Arbitrations shall be conducted according to the Rules of
that the Office of the Independent Administrator waive
                                                             Procedure developed by the Office of the Independent
the filing fee and the neutral arbitrator's fees and
                                                             Administrator in consultation with Kaiser Permanente
expenses. A Claimant who seeks such waivers shall
                                                             and the Arbitration Oversight Board. Copies of the Rules
complete the Fee Waiver Form and submit it to the
Office of the Independent Administrator and


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                       Page 46
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
of Procedure may be obtained from our Member Service                   How You May Terminate Your
Call Center.                                                           Membership
General provisions                                                      You may terminate your membership by sending written
A claim shall be waived and forever barred if (1) on the                notice, signed by the Subscriber, to the address below.
date the Demand for Arbitration of the claim is served,                 Your membership will terminate at 11:59 p.m. on the last
the claim, if asserted in a civil action, would be barred as            day of the month in which we receive your notice. Also,
to the Respondents served by the applicable statute of                  you must include with your notice all amounts payable
limitations, (2) Claimants fail to pursue the arbitration               related to this Membership Agreement and Evidence of
claim in accord with the Rules of Procedure with                        Coverage, including Premiums, for the period prior to
reasonable diligence, or (3) the arbitration hearing is not             your termination date.
commenced within five years after the earlier of (a) the                      Kaiser Foundation Health Plan, Inc.
date the Demand for Arbitration was served in accord                          California Service Center
with the procedures prescribed herein, or (b) the date of                     P.O. Box 23127
filing of a civil action based upon the same incident,                        San Diego, CA 92193-3127
transaction, or related circumstances involved in the
claim. A claim may be dismissed on other grounds by the
neutral arbitrator based on a showing of a good cause.                 Termination Due to Loss of Eligibility
If a party fails to attend the arbitration hearing after
being given due notice thereof, the neutral arbitrator may              If you meet the eligibility requirements described under
proceed to determine the controversy in the party's                     "Who Is Eligible" in the "Premiums, Eligibility, and
absence.                                                                Enrollment" section on the first day of a month, but later
                                                                        in that month you no longer meet those eligibility
The California Medical Injury Compensation Reform                       requirements, your membership will end at 11:59 p.m. on
Act of 1975 (including any amendments thereto),                         the last day of that month. For example, if you become
including sections establishing the right to introduce                  ineligible on December 5, 2010, your termination date is
evidence of any insurance or disability benefit payment                 January 1, 2011, and your last minute of coverage is at
to the patient, the limitation on recovery for                          11:59 p.m. on December 31, 2010.
noneconomic losses, and the right to have an award for
future damages conformed to periodic payments, shall
                                                                       Termination for Cause
apply to any claims for professional negligence or any
other claims as permitted or required by law.                           If you commit one of the following acts, we may
                                                                        terminate your membership immediately by sending
Arbitrations shall be governed by this "Binding                         written notice to the Subscriber; termination will be
Arbitration" section, Section 2 of the Federal Arbitration              effective on the date we send the notice:
Act, and the California Code of Civil Procedure
                                                                        • You intentionally commit fraud in connection with
provisions relating to arbitration that are in effect at the
                                                                          membership, Health Plan, or a Plan Provider. Some
time the statute is applied, together with the Rules of
                                                                          examples of fraud include:
Procedure, to the extent not inconsistent with this
"Binding Arbitration" section.                                             ♦ misrepresenting eligibility information about you
                                                                               or a Dependent
                                                                           ♦ presenting an invalid prescription or physician
                                                                               order
Termination of Membership
                                                                           ♦ misusing a Kaiser Permanente ID card (or letting
                                                                               someone else use it)
Your membership termination date is the first day you
are not covered (for example, if your termination date is                  ♦ giving us incorrect or incomplete material
January 1, 2011, your last minute of coverage was at                           information
11:59 p.m. on December 31, 2010). You will be billed as                    ♦ failing to notify us of changes in family status or
a non-Member for any Services you receive after your                           Medicare coverage that may affect your eligibility
membership terminates. When your membership                                    or benefits
terminates, Health Plan and Plan Providers have no
further liability or responsibility under this Membership               After your first 24 months of individuals and families
Agreement and Evidence of Coverage, except as                           coverage, we may not terminate you for cause solely
provided under "Payments after Termination" in this                     because you gave us incorrect or incomplete material
"Termination of Membership" section.                                    information in your Health Coverage Application.


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 47
If we terminate your membership for cause, you will not      If we terminate this Membership Agreement and
be allowed to enroll in Health Plan in the future. We may    Evidence of Coverage for nonpayment of Premiums, we
also report criminal fraud and other illegal acts to the     will permit reinstatement of this Membership Agreement
authorities for prosecution.                                 and Evidence of Coverage three times during any 12-
                                                             month period if we receive the amounts owed within 15
                                                             days of the date of the Late Notice. We will not reinstate
Termination for Nonpayment of                                this Membership Agreement and Evidence of Coverage
Premiums                                                     if you do not obtain reinstatement of your terminated
                                                             Membership Agreement and Evidence of Coverage
If we terminate this Membership Agreement and                within the required 15 days, or if we terminate the
Evidence of Coverage because we did not receive the          Membership Agreement and Evidence of Coverage for
required Premiums when due, then the membership of           nonpayment of Premiums more than three times in a 12-
the Subscriber will end retroactively at 11:59 p.m. on the   month period.
last day of the most recent month for which we received
a full Premium payment. This retroactive period will not
exceed 60 days before the date we mail the Subscriber a      Termination for Discontinuance of a
notice confirming termination of membership (a               Product
"Termination Notice").
                                                             We may terminate your membership if we discontinue
If we do not receive full Premium payment on or before       offering this product as permitted or required by law.
the 20th day of the coverage month, we will send a           If we continue to offer other individual (nongroup)
notice of nonreceipt of payment (a "Late Notice") to the     products, we may terminate your membership under this
Subscriber's address of record. This Late Notice will        product by sending you written notice at least 90 days
include the following information:                           before the termination date. You will be able to enroll in
                                                             any other product we are then offering in the individual
• A statement that we have not received full Premium
                                                             (nongroup) market if you meet all eligibility
  payment and that we will terminate this Membership
                                                             requirements (except for any medical review
  Agreement and Evidence of Coverage for
                                                             requirement). If we discontinue offering all individual
  nonpayment if we do not receive the required
                                                             (nongroup) products, we may terminate your
  Premiums within 30 days after the date we mailed the
                                                             membership by sending you written notice at least 180
  Late Notice
                                                             days before the termination date.
• The specific date and time when the membership of
  the Subscriber will end if we do not receive the
  required Premiums                                          Payments after Termination

We will mail a Termination Notice to the Subscriber's        If we terminate your membership for cause or for
address of record if we do not receive full Premium          nonpayment, we will:
payment within 30 days after the date we mailed the Late     • Within 30 days, refund any amounts we owe for
Notice. The Termination Notice will include the                Premiums you paid after the termination date
following information:
                                                             • Pay you any amounts we have determined that we
• A statement that we have terminated this Membership          owe you for claims during your membership in
  Agreement and Evidence of Coverage for                       accord with the "Emergency Services and Urgent
  nonpayment of Premiums                                       Care" and "Dispute Resolution" sections
• The specific date and time when the membership of
  the Subscriber ended                                       We will deduct any amounts you owe Health Plan or
                                                             Plan Providers from any payment we make to you.
• Information explaining whether or not the Subscriber
  can reinstate this Membership Agreement and
  Evidence of Coverage                                       State Review of Membership
                                                             Termination
Reinstatement after termination for nonpayment
of Premiums                                                  If you believe that we terminated your membership
Persons terminated for nonpayment of Premiums may            because of your ill health or your need for care, you may
not enroll in Health Plan even after paying all amounts      request a review of the termination by the California
owed unless we approve the enrollment.                       Department of Managed Health Care (please see




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                      Page 48
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
"Department of Managed Health Care Complaints" in the                   claims for money due, benefits, or obligations hereunder
"Dispute Resolution" section).                                          without our prior written consent.

                                                                        Attorney and advocate fees and expenses
Miscellaneous Provisions                                                In any dispute between a Member and Health Plan, the
                                                                        Medical Group, or Kaiser Foundation Hospitals, each
                                                                        party will bear its own fees and expenses, including
Administration of this Membership Agreement
                                                                        attorneys' fees, advocates' fees, and other expenses.
and Evidence of Coverage
We may adopt reasonable policies, procedures, and                       Claims review authority
interpretations to promote orderly and efficient
                                                                        We are responsible for determining whether you are
administration of this Membership Agreement and
                                                                        entitled to benefits under this Membership Agreement
Evidence of Coverage.
                                                                        and Evidence of Coverage and we have the discretionary
                                                                        authority to review and evaluate claims that arise under
Advance directives
                                                                        this Membership Agreement and Evidence of Coverage.
The California Health Care Decision Law offers several                  We conduct this evaluation independently by interpreting
ways for you to control the kind of health care you will                the provisions of this Membership Agreement and
receive if you become very ill or unconscious, including                Evidence of Coverage. If coverage under this
the following:                                                          Membership Agreement and Evidence of Coverage is
• A Power of Attorney for Health Care lets you name                     subject to the Employee Retirement Income Security Act
  someone to make health care decisions for you when                    (ERISA) claims procedure regulation (29 CFR 2560.503-
  you cannot speak for yourself. It also lets you write                 1), then we are a "named claims fiduciary" to review
  down your own views on life support and other                         claims under this Membership Agreement and Evidence
  treatments                                                            of Coverage.
• Individual health care instructions let you express
                                                                        Governing law
  your wishes about receiving life support and other
  treatment. You can express these wishes to your                       Except as preempted by federal law, this Membership
  doctor and have them documented in your medical                       Agreement and Evidence of Coverage will be governed
  chart, or you can put them in writing and have that                   in accord with California law and any provision that is
  included in your medical chart                                        required to be in this Membership Agreement and
                                                                        Evidence of Coverage by state or federal law shall bind
To learn more about advance directives, including how                   Members and Health Plan whether or not set forth in this
to obtain forms and instructions, contact your local                    Membership Agreement and Evidence of Coverage.
Member Services Department at a Plan Facility. You can
also refer to Your Guidebook for more information about                 Health Insurance Counseling and Advocacy
advance directives.                                                     Program (HICAP)
                                                                        For additional information concerning benefits, contact
Membership Agreement and Evidence of                                    the Health Insurance Counseling and Advocacy Program
Coverage binding on Members                                             (HICAP) or your agent. HICAP provides health
By electing coverage or accepting benefits under this                   insurance counseling for California senior citizens. Call
Membership Agreement and Evidence of Coverage, all                      HICAP toll free at 1-800-434-0222 (TTY users call 711)
Members legally capable of contracting, and the legal                   for a referral to your local HICAP office. HICAP is a
representatives of all Members incapable of contracting,                free service provided by the state of California.
agree to all provisions of this Membership Agreement
and Evidence of Coverage.                                               No waiver
                                                                        Our failure to enforce any provision of this Membership
Applications and statements                                             Agreement and Evidence of Coverage will not constitute
You must complete any applications, forms, or                           a waiver of that or any other provision, or impair our
statements that we request in our normal course of                      right thereafter to require your strict performance of any
business or as specified in this Membership Agreement                   provision.
and Evidence of Coverage.
                                                                        Nondiscrimination
Assignment                                                              We do not discriminate in our employment practices or
You may not assign this Membership Agreement and                        in the delivery of Services on the basis of age, race,
Evidence of Coverage or any of the rights, interests,                   color, national origin, cultural background, religion, sex,


Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 49
sexual orientation, physical or mental disability, or         written authorization, except as described in our Notice
genetic information.                                          of Privacy Practices (see below). Giving us authorization
                                                              is at your discretion.
Notices
Our notices to you will be sent to the most recent address    This is only a brief summary of some of our key
we have for the Subscriber, except that if the Subscriber     privacy practices. Our Notice of Privacy Practices,
has chosen to receive these membership agreement and          which provides additional information about our
evidence of coverage documents online we will notify          privacy practices and your rights regarding your
the Subscriber at the most recent email address we have       protected health information is available and will be
for the Subscriber when notices related to amendment of       furnished to you upon request. To request a copy,
this Membership Agreement and Evidence of Coverage            please call our Member Service Call Center. You can
are posted on our website at kp.org. The Subscriber is        also find the notice at your local Plan Facility or on
responsible for notifying us of any change in address.        our website at kp.org.
Subscribers who move (or change their e-mail address if
the Subscriber has chosen to receive these membership         Public policy participation
agreement and evidence of coverage documents on our           The Kaiser Foundation Health Plan, Inc., Board of
website) should call our Member Service Call Center as        Directors establishes public policy for Health Plan. A list
soon as possible to give us their new address. If a           of the Board of Directors is available on our website at
Member does not reside with the Subscriber, he or she         kp.org or from our Member Service Call Center. If you
should contact our Member Service Call Center to              would like to provide input about Health Plan public
discuss alternate delivery options.                           policy for consideration by the Board, please send
                                                              written comments to:
Other formats for Members with disabilities                        Kaiser Foundation Health Plan, Inc.
You can request a copy of this Membership Agreement                Office of Board and Corporate Governance Services
and Evidence of Coverage in an alternate format (Braille,          One Kaiser Plaza, 19th Floor
audio, electronic text file, or large print) by calling our        Oakland, CA 94612
Member Service Call Center.
                                                              Telephone access (TTY)
Overpayment recovery                                          If you are hearing or speech impaired and use a text
We may recover any overpayment we make for Services           telephone device (TTY, also known as TDD) to
from anyone who receives such an overpayment or from          communicate by phone, you can use the California Relay
any person or organization obligated to pay for the           Service by calling 711 if a dedicated TTY number is not
Services.                                                     available for the telephone number that you want to call.

Privacy practices
Kaiser Permanente will protect the privacy of your            Helpful Information
protected health information. We also require contracting
providers to protect your protected health information.
Your protected health information is individually-            Your Guidebook to Kaiser Permanente
identifiable information (oral, written, or electronic)       Services (Your Guidebook)
about your health, health care services you receive, or
                                                              Please refer to Your Guidebook for helpful information
payment for your health care. You may generally see and
                                                              about your coverage, such as:
receive copies of your protected health information,
correct or update your protected health information, and      • The types of covered Services that are available from
ask us for an accounting of certain disclosures of your         each Plan Facility in your area
protected health information.                                 • How to use our Services and make appointments

We may use or disclose your protected health                  • Hours of operation
information for treatment, health research, payment, and      • Appointments and advice phone numbers
health care operations purposes, such as measuring the
quality of Services. We are sometimes required by law to      You can get a copy of Your Guidebook by visiting our
give protected health information to others, such as          website at kp.org or by calling our Member Service Call
government agencies or in judicial actions. We will not       Center.
use or disclose your protected health information for any
other purpose without your (or your representative's)



Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                       Page 50
                                                   Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                       weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

How to Reach Us                                                                        711 (TTY)
Appointments                                                                           Call any time
If you need to make an appointment, please call us or
visit our website:                                                      Help with claim forms for Emergency Services,
                                                                        Post-Stabilization Care, Out-of-Area Urgent
Call            The appointment phone number at a                       Care, and emergency ambulance Services
                Plan Facility (refer to Your Guidebook                  If you need a claim form to request payment or
                or the facility directory on our website                reimbursement for Services described in the "Emergency
                at kp.org for phone numbers)                            Services and Urgent Care" section or under "Ambulance
Website         kp.org for routine (non-urgent)                         Services" in the "Benefits and Cost Sharing" section, or
                appointments with your personal Plan                    if you need help completing the form, you can reach us
                Physician or another Primary Care                       by calling or by visiting our website.
                Physician
                                                                        Call           1-800-464-4000 or 1-800-390-3510
Not sure what kind of care you need?
                                                                                       1-800-777-1370 (TTY)
If you need advice on whether to get medical care, or
how and when to get care, we have licensed health care                                 Weekdays 7 a.m. to 7 p.m., and
professionals available to assist you by phone 24 hours a                              weekends 7 a.m. to 3 p.m. (except
day, 7 days a week:                                                                    holidays)
                                                                        Website        kp.org
Call            The appointment or advice phone
                number at a Plan Facility (refer to Your
                                                                        Submitting claims for Emergency Services,
                Guidebook or the facility directory on
                                                                        Post-Stabilization Care, Out-of-Area Urgent
                our website at kp.org for phone
                                                                        Care, and emergency ambulance Services
                numbers)
                                                                        If you need to submit a completed claim form for
Member Services                                                         Services described in the "Emergency Services and
                                                                        Urgent Care" section or under "Ambulance Services" in
If you have questions or concerns about your coverage,
                                                                        the "Benefits and Cost Sharing" section, or if you need to
how to obtain Services, or the facilities where you can
                                                                        submit other information that we request about your
receive care, you can reach us by calling, writing, or
                                                                        claim, send it to our Claims Department:
visiting our website:
                                                                        Write          Kaiser Foundation Health Plan, Inc.
Call            1-800-464-4000
                                                                                       Claims Department
                1-800-390-3510 (TTY)                                                   P.O. Box 7004
                                                                                       Downey, CA 90242-7004
                Weekdays 7 a.m. to 7 p.m., and
                weekends 7 a.m. to 3 p.m. (except
                holidays)                                              Payment Responsibility
Write           Member Services Department at a Plan
                                                                        This "Payment Responsibility" section briefly explains
                Facility (refer to Your Guidebook for
                                                                        who is responsible for payments related to the health care
                addresses)
                                                                        coverage described in this Membership Agreement and
Website         kp.org                                                  Evidence of Coverage. Payment responsibility is more
                                                                        fully described in other sections of the Membership
Authorization for Post-Stabilization Care                               Agreement and Evidence of Coverage as described
If you need to request authorization for Post-Stabilization             below:
Care as described under "Emergency Services" in the                     • The Subscriber is responsible for paying Premiums
"Emergency Services and Urgent Care" section, please                      (refer to "Premiums" in the "Premiums, Eligibility,
call us:                                                                  and Enrollment" section)

Call           1-800-225-8883 or the notification                       • You are responsible for paying Cost Sharing for
               telephone number on your Kaiser                            covered Services (refer to "Cost Sharing" in the
               Permanente ID card                                         "Benefits and Cost Sharing" section)




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                                                                                   Page 51
• If you receive Emergency Services, Post-Stabilization
  Care, or Out-of-Area Urgent Care from a Non–Plan
  Provider, or if you receive emergency ambulance
  Services, you must pay the provider and file a claim
  for reimbursement unless the provider agrees to bill
  us (refer to "Payment and Reimbursement" in the
  "Emergency Services and Urgent Care" section)
• If you receive Services from Non–Plan Providers that
  we did not authorize (other than Emergency Services,
  Post-Stabilization Care, Out-of-Area Urgent Care, or
  emergency ambulance Services) and you want us to
  pay for the care, you must submit a grievance (refer
  to "Grievances" in the "Dispute Resolution" section)
• If you have Medicare, we will coordinate benefits
  with the other coverage (refer to "Coordination of
  Benefits" in the "Exclusions, Limitations,
  Coordination of Benefits, and Reductions" section)
• In some situations, you or a third party may be
  responsible for reimbursing us for covered Services
  (refer to "Reductions" in the "Exclusions,
  Limitations, Coordination of Benefits, and
  Reductions" section)
• You are responsible for paying the full price for
  noncovered Services




Kaiser Permanente Individual—Conversion Copayment 25 Plan
Date: September 30, 2010                                    Page 52
Kaiser Foundation Health Plan, Inc.
Southern California Region

A nonprofit corporation


Individual Plan Membership Agreement and
Disclosure Form and Evidence of Coverage for
Kaiser Permanente Individual—Conversion Plan


Deductible 30/1500 Plan




Highlights
Deductible for certain Services ..................... $1,500 per calendar year
Copayments and Coinsurance after Deductible is met:
Most consultations and exams....................... $30 per visit (Deductible doesn't apply)
Hospital inpatient care................................... $500 per day after Deductible
Outpatient surgery ......................................... $250 per procedure after Deductible
Emergency Department visits ....................... $150 per visit after Deductible
Generic drugs ................................................ $10 for up to a 30-day supply (Deductible doesn't apply)
Brand-name drugs ......................................... $35 for up to a 30-day supply (Deductible doesn't apply)




                                                           Member Service Call Center
                                                           Weekdays 7 a.m.–7 p.m.; weekends 7 a.m.–3 p.m.
                                                           (except holidays)
                                                           1-800-464-4000 toll free
                                                           1-800-777-1370 (toll free TTY for the hearing/speech impaired)
                                                           kp.org
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.




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VERSION_DESCRIPTION MANUAL C1V3 2011 RENEWAL RATES FID 39142374 TAMMYS X7977
REASON_FOR_NEW_VERSION RENEWED
VER_REN_DATE 01/01/2011
TABLE OF CONTENTS
Health Plan Benefits and Coverage Matrix .......................................................................................................................... 1
Introduction .......................................................................................................................................................................... 3
   Term of this Membership Agreement and Evidence of Coverage, Renewal, and Amendment........................................ 3
   About Kaiser Permanente................................................................................................................................................. 4
Definitions............................................................................................................................................................................ 4
Premiums, Eligibility, and Enrollment ................................................................................................................................. 7
   Premiums.......................................................................................................................................................................... 7
   Who Is Eligible................................................................................................................................................................. 8
   How to Enroll ................................................................................................................................................................... 9
How to Obtain Services........................................................................................................................................................ 9
   Routine Care..................................................................................................................................................................... 9
   Urgent Care .................................................................................................................................................................... 10
   Not Sure What Kind of Care You Need? ....................................................................................................................... 10
   Your Personal Plan Physician ........................................................................................................................................ 10
   Getting a Referral ........................................................................................................................................................... 10
   Second Opinions ............................................................................................................................................................ 12
   Contracts with Plan Providers ........................................................................................................................................ 12
   Visiting Other Regions................................................................................................................................................... 13
   Your ID Card.................................................................................................................................................................. 13
   Getting Assistance.......................................................................................................................................................... 13
Plan Facilities ..................................................................................................................................................................... 14
   Plan Hospitals and Plan Medical Offices ....................................................................................................................... 14
   Your Guidebook to Kaiser Permanente Services (Your Guidebook).............................................................................. 17
Emergency Services and Urgent Care................................................................................................................................ 17
   Emergency Services ....................................................................................................................................................... 17
   Urgent Care .................................................................................................................................................................... 18
   Payment and Reimbursement ......................................................................................................................................... 18
Benefits and Cost Sharing .................................................................................................................................................. 19
   Cost Sharing ................................................................................................................................................................... 20
   Preventive Care Services................................................................................................................................................ 22
   Outpatient Care .............................................................................................................................................................. 22
   Hospital Inpatient Care................................................................................................................................................... 24
   Ambulance Services....................................................................................................................................................... 24
   Bariatric Surgery ............................................................................................................................................................ 25
   Chemical Dependency Services ..................................................................................................................................... 25
   Dental and Orthodontic Services.................................................................................................................................... 26
   Dialysis Care .................................................................................................................................................................. 27
   Durable Medical Equipment for Home Use ................................................................................................................... 28
   Health Education ............................................................................................................................................................ 29
   Hearing Services ............................................................................................................................................................ 29
   Home Health Care.......................................................................................................................................................... 29
   Hospice Care .................................................................................................................................................................. 30
   Mental Health Services .................................................................................................................................................. 31
   Ostomy and Urological Supplies.................................................................................................................................... 32
   Outpatient Imaging, Laboratory, and Special Procedures .............................................................................................. 33
   Outpatient Prescription Drugs, Supplies, and Supplements ........................................................................................... 33
   Prosthetic and Orthotic Devices ..................................................................................................................................... 36
   Reconstructive Surgery .................................................................................................................................................. 36
   Services Associated with Clinical Trials ........................................................................................................................ 37
  Skilled Nursing Facility Care ......................................................................................................................................... 37
  Transplant Services ........................................................................................................................................................ 38
  Vision Services............................................................................................................................................................... 38
Exclusions, Limitations, Coordination of Benefits, and Reductions .................................................................................. 39
  Exclusions ...................................................................................................................................................................... 39
  Limitations ..................................................................................................................................................................... 41
  Coordination of Benefits ................................................................................................................................................ 42
  Reductions...................................................................................................................................................................... 42
Dispute Resolution ............................................................................................................................................................. 43
  Grievances...................................................................................................................................................................... 43
  Supporting Documents ................................................................................................................................................... 45
  Who May File................................................................................................................................................................. 45
  Department of Managed Health Care Complaints.......................................................................................................... 45
  Independent Medical Review (IMR).............................................................................................................................. 45
  Binding Arbitration ........................................................................................................................................................ 46
Termination of Membership............................................................................................................................................... 48
  How You May Terminate Your Membership ................................................................................................................ 49
  Termination Due to Loss of Eligibility .......................................................................................................................... 49
  Termination for Cause.................................................................................................................................................... 49
  Termination for Nonpayment of Premiums.................................................................................................................... 49
  Termination for Discontinuance of a Product ................................................................................................................ 50
  Payments after Termination ........................................................................................................................................... 50
  State Review of Membership Termination..................................................................................................................... 50
Miscellaneous Provisions ................................................................................................................................................... 50
Helpful Information............................................................................................................................................................ 52
  Your Guidebook to Kaiser Permanente Services (Your Guidebook)............................................................................. 52
  How to Reach Us............................................................................................................................................................ 52
  Payment Responsibility.................................................................................................................................................. 53
Chiropractic Services Amendment..................................................................................................................................... 53
  Definitions...................................................................................................................................................................... 54
  Participating Providers ................................................................................................................................................... 54
  Covered Services............................................................................................................................................................ 54
  Exclusions and Limitations ............................................................................................................................................ 56
  Member Services............................................................................................................................................................ 57
  Grievances...................................................................................................................................................................... 57
Health Plan Benefits and Coverage Matrix
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR
A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
Annual Out-of-Pocket Maximum for Certain Services                        $3,500 per calendar year
For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Copayments and
 Coinsurance you pay for those Services, plus all your Deductible payments, add up to this amount.
Deductible for Certain Services as specified below                        $1,500 per calendar year
You must pay Charges for Services you receive in a calendar year until you reach this Deductible amount.
Lifetime Maximum                                                                                             None
Professional Services (Plan Provider office visits)                                                          You Pay
Most primary and specialty care consultations and exams..........................                            $30 per visit (Deductible doesn't apply)
Routine physical maintenance exams..........................................................                 No charge (Deductible doesn't apply)
Well-child preventive exams (through age 23 months)...............................                           No charge (Deductible doesn't apply)
Family planning counseling ........................................................................          No charge (Deductible doesn't apply)
Scheduled prenatal care exams and first postpartum follow-up
                                                                                               No charge (Deductible doesn't apply)
 consultation and exam...............................................................................
                                                                                               No charge (Deductible doesn't apply)
Eye exams for refraction .............................................................................
                                                                                               No charge (Deductible doesn't apply)
Hearing exams.............................................................................................
Chiropractic consultations and exams.........................................................  $15 per visit (up to a total of 20 visits per calendar
                                                                                                year)
Urgent care consultations and exams .......................................................... $30 per visit (Deductible doesn't apply)
Physical, occupational, and speech therapy ................................................ $30 per visit after Deductible
Outpatient Services                                                                                          You Pay
Outpatient surgery and certain other outpatient procedures ........................                          $250 per procedure after Deductible
Allergy injections (including allergy serum)...............................................                  $5 per visit after Deductible
Most immunizations (including vaccines) ..................................................                   No charge (Deductible doesn't apply)
Most X-rays and laboratory tests.................................................................            $10 per encounter after Deductible
Preventive X-rays, screenings, and laboratory tests as described in the
 "Benefits and Cost Sharing" section..........................................................               No charge (Deductible doesn't apply)
MRI, most CT, and PET scans....................................................................              $50 per procedure after Deductible
Health education:
   Covered individual health education counseling and programs.............                                  No charge (Deductible doesn't apply)
   Covered group education programs .......................................................                  No charge (Deductible doesn't apply)
Hospitalization Services                                                   You Pay
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs . $500 per day after Deductible
Emergency Health Coverage                                                                         You Pay
Emergency Department visits ..................................................................... $150 per visit after Deductible
Note: After you meet the Deductible, this Cost Sharing does not apply if admitted directly to the hospital as an inpatient for
 covered Services (see "Hospitalization Services" for inpatient Cost Sharing).
Ambulance Services                                                                                     You Pay
Ambulance Services.................................................................................... $150 per trip after Deductible




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                                                Page 1
Prescription Drug Coverage                                                                 You Pay
Most covered outpatient items in accord with our drug formulary
 guidelines:
   Generic items from a Plan Pharmacy..................................................... $10 for up to a 30-day supply, $20 for a 31- to 60-
                                                                                            day supply, or $30 for a 61- to 100-day supply
                                                                                            (Deductible doesn't apply)
   Generic refills from our mail-order service............................................ $10 for up to a 30-day supply or $20 for a 31- to
                                                                                            100-day supply (Deductible doesn't apply)
   Brand-name items from a Plan Pharmacy.............................................. $35 for up to a 30-day supply, $70 for a 31- to 60-
                                                                                            day supply, or $105 for a 61- to 100-day supply
                                                                                            (Deductible doesn't apply)
   Brand-name refills from our mail-order service..................................... $35 for up to a 30-day supply or $70 for a 31- to
                                                                                            100-day supply (Deductible doesn't apply)
Durable Medical Equipment                                               You Pay
The durable medical equipment for home use listed in the "Benefits and
 Cost Sharing" section in accord with our durable medical equipment
 formulary guidelines (most durable medical equipment is not covered) . 30% Coinsurance (Deductible doesn't apply)
Mental Health Services                                                                                You Pay
Inpatient psychiatric hospitalization and intensive psychiatric treatment
 programs (up to 10 days per calendar year) .............................................. $500 per day after Deductible
Outpatient mental health evaluations and treatments:
   Up to a total of 10 individual and group visits per calendar year that                             $30 per individual visit (Deductible doesn't apply)
     include Services for mental health evaluation or treatment ................. $15 per group visit (Deductible doesn't apply)
   Up to 30 additional group visits in the same calendar year that meet
     Medical Group criteria ......................................................................... $15 per visit (Deductible doesn't apply)
Note: Visit and day limits do not apply to Serious Emotional Disturbances of children and Severe Mental Illnesses as described
 in the "Benefits and Cost Sharing" section.
Chemical Dependency Services                                                                               You Pay
Inpatient detoxification ...............................................................................   $500 per day after Deductible
Individual outpatient chemical dependency consultations and treatment ...                                  $30 per visit (Deductible doesn't apply)
Group outpatient chemical dependency treatment ......................................                      $5 per visit (Deductible doesn't apply)
Transitional residential recovery Services (up to 60 days per calendar
 year, not to exceed 120 days in any five-year period)...............................                      $100 per admission after Deductible
Home Health Services                                                                   You Pay
Home health care (up to 100 visits per calendar year) ................................ No charge (Deductible doesn't apply)
Other                                                                                                        You Pay
Skilled Nursing Facility care (up to 60 days per benefit period)................. $50 per day after Deductible
Hospice care................................................................................................ No charge (Deductible doesn't apply)

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




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                                              Page 2
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Introduction                                                            Term of this Membership Agreement and
                                                                        Evidence of Coverage, Renewal, and
This Individual Plan Membership Agreement and                           Amendment
Disclosure Form and Evidence of Coverage
(Membership Agreement and Evidence of Coverage)                          Term of this Membership Agreement and
describes the health care coverage of "Kaiser Permanente                 Evidence of Coverage
Individual—Conversion Deductible 30/1500 Plan." This                     This Membership Agreement and Evidence of Coverage
Membership Agreement and Evidence of Coverage, the                       becomes effective on the membership effective date in
Rate Sheet which is incorporated into this Membership                    the Subscriber's acceptance letter and will remain in
Agreement and Evidence of Coverage by reference, and                     effect until one of the following occurs:
any amendments, constitute the legally binding contract                  • The Membership Agreement and Evidence of
between Health Plan (Kaiser Foundation Health Plan,                        Coverage is amended as described under
Inc.) and the Subscriber. For benefits provided under any                  "Amendment of Membership Agreement and
other Health Plan program, refer to that plan's evidence                   Evidence of Coverage" in this "Introduction" section
of coverage.
                                                                         • There are no longer any Members in your Family
                                                                           who are covered under this Membership Agreement
In this Membership Agreement and Evidence of
                                                                           and Evidence of Coverage
Coverage, Health Plan is sometimes referred to as "we"
or "us." Members are sometimes referred to as "you."
Some capitalized terms have special meaning in this                      Note: Your membership may terminate even if this
Membership Agreement and Evidence of Coverage;                           Membership Agreement and Evidence of Coverage
please see the "Definitions" section for terms you should                remains in effect for other covered Members of your
know.                                                                    Family. The "Termination of Membership" section
                                                                         explains how membership may terminate.
The "Kaiser Permanente Individual—Conversion Plan"
                                                                         Renewal
does not include dependent coverage, so each person in
your family who is accepted for coverage must enroll as                  If you comply with all the terms of this Membership
a Subscriber under his or her own Membership                             Agreement and Evidence of Coverage, we will
Agreement and Evidence of Coverage as described under                    automatically renew this Membership Agreement and
"Who Is Eligible" and "How to Enroll" in the                             Evidence of Coverage each year, effective on one of the
"Premiums, Eligibility, and Enrollment" section. Any                     following dates:
references in this Membership Agreement and Evidence                     • January 1 if the most recent effective date of the
of Coverage to Dependents, Spouses, or children are not                    Subscriber's coverage is between January 1 and June
applicable to your coverage.                                               30
                                                                         • July 1 if the most recent effective date of the
Please read the following information so that you will
                                                                           Subscriber's coverage is between July 1 and
know from whom or what group of providers you                              December 31
may get health care. It is important to familiarize
yourself with your coverage by reading this Membership
                                                                         Terms of the Membership Agreement and Evidence of
Agreement and Evidence of Coverage completely, so that
                                                                         Coverage will remain the same when we renew it unless
you can take full advantage of your Health Plan benefits.
                                                                         we have amended the Membership Agreement and
Also, if you have special health care needs, please
                                                                         Evidence of Coverage as described under "Amendment
carefully read the sections that apply to you.
                                                                         of Membership Agreement and Evidence of Coverage" in
                                                                         this "Term of this Membership Agreement and Evidence
Note: The Health Plan Benefits and Coverage Matrix is
                                                                         of Coverage, Renewal, and Amendment" section.
located in the front of this Membership Agreement and
Evidence of Coverage.
                                                                         Amendment of Membership Agreement and
                                                                         Evidence of Coverage
                                                                         In accord with "Notices" in the "Miscellaneous
                                                                         Provisions" section, we may amend this Membership
                                                                         Agreement and Evidence of Coverage (including
                                                                         Premiums and benefits) at any time by sending
                                                                         written notice to the Subscriber at least 30 days
                                                                         before the effective date of the amendment. The



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 3
amendment may become effective earlier than the end of            Definitions
the period for which you have already paid your
Premiums, and it may require you to pay additional
                                                                  Some terms have special meaning in this Membership
Premiums for that period. All amendments are deemed
                                                                  Agreement and Evidence of Coverage. When we use a
accepted by the Subscriber unless the Subscriber gives us
                                                                  term with special meaning in only one section of this
written notice of non-acceptance within 30 days of the
                                                                  Membership Agreement and Evidence of Coverage, we
date of the notice, in which case this Membership
                                                                  define it in that section. The terms in this "Definitions"
Agreement and Evidence of Coverage terminates the day
                                                                  section have special meaning when capitalized and used
before the effective date of the amendment.
                                                                  in any section of this Membership Agreement and
                                                                  Evidence of Coverage.
If we notified the Subscriber that we have not received
all necessary governmental approvals related to this              Charges: "Charges" means the following:
Membership Agreement and Evidence of Coverage, we                 • For Services provided by the Medical Group or
may amend this Membership Agreement and Evidence of                 Kaiser Foundation Hospitals, the charges in Health
Coverage by giving written notice to the Subscriber after           Plan's schedule of Medical Group and Kaiser
receiving all necessary governmental approval, in accord            Foundation Hospitals charges for Services provided
with "Notices" in the "Miscellaneous Provisions"                    to Members
section. Any such government-approved provisions go
into effect on January 1, 2011 (unless the government             • For Services for which a provider (other than the
requires a later effective date).                                   Medical Group or Kaiser Foundation Hospitals) is
                                                                    compensated on a capitation basis, the charges in the
                                                                    schedule of charges that Kaiser Permanente
About Kaiser Permanente                                             negotiates with the capitated provider
                                                                  • For items obtained at a pharmacy owned and operated
Kaiser Permanente provides Services directly to our
                                                                    by Kaiser Permanente, the amount the pharmacy
Members through an integrated medical care program.
                                                                    would charge a Member for the item if a Member's
Health Plan, Plan Hospitals, and the Medical Group
                                                                    benefit plan did not cover the item (this amount is an
work together to provide our Members with quality care.
                                                                    estimate of: the cost of acquiring, storing, and
Our medical care program gives you access to all of the
                                                                    dispensing drugs, the direct and indirect costs of
covered Services you may need, such as routine care
                                                                    providing Kaiser Permanente pharmacy Services to
with your own personal Plan Physician, hospital care,
                                                                    Members, and the pharmacy program's contribution
laboratory and pharmacy Services, Emergency Services,
                                                                    to the net revenue requirements of Health Plan)
Urgent Care, and other benefits described in the
"Benefits and Cost Sharing" section. Plus, our health             • For all other Services, the payments that Kaiser
education programs offer you great ways to protect and              Permanente makes for the Services or, if Kaiser
improve your health.                                                Permanente subtracts Cost Sharing from its payment,
                                                                    the amount Kaiser Permanente would have paid if it
We provide covered Services to Members using Plan                   did not subtract Cost Sharing
Providers located in our Service Area, which is described         Coinsurance: A percentage of Charges that you must
in the "Definitions" section. You must receive all                pay when you receive a covered Service as described in
covered care from Plan Providers inside our Service               the "Benefits and Cost Sharing" section.
Area, except as described in the sections listed below for
the following Services:                                           Copayment: A specific dollar amount that you must pay
                                                                  when you receive a covered Service as described in the
• Authorized referrals as described under "Getting a
                                                                  "Benefits and Cost Sharing" section. Note: The dollar
  Referral" in the "How to Obtain Services" section
                                                                  amount of the Copayment can be $0 (no charge).
• Emergency ambulance Services as described under
                                                                  Cost Sharing: The amount you are required to pay for a
  "Ambulance Services" in the "Benefits and Cost
                                                                  covered Service, for example: the Deductible,
  Sharing" section
                                                                  Copayment, or Coinsurance.
• Emergency Services, Post-Stabilization Care, and
  Out-of-Area Urgent Care as described in the                     Deductible: The amount you must pay in a calendar year
  "Emergency Services and Urgent Care" section                    for certain Services before we will cover those Services
                                                                  at the applicable Copayment or Coinsurance in that
• Hospice care as described under "Hospice Care" in               calendar year. Please refer to the "Benefits and Cost
  the "Benefits and Cost Sharing" section                         Sharing" section for the Services that are subject to the
                                                                  Deductible(s) and the Deductible amount(s).



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 4
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
Dependent: A Member who meets the eligibility                            Medically Necessary: A Service is Medically Necessary
requirements as a Dependent.                                             if it is medically appropriate and required to prevent,
                                                                         diagnose, or treat your condition or clinical symptoms in
Emergency Medical Condition: A medical condition
                                                                         accord with generally accepted professional standards of
manifesting itself by acute symptoms of sufficient
                                                                         practice that are consistent with a standard of care in the
severity (including severe pain) such that a prudent
                                                                         medical community.
layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the                         Medicare: The federal health insurance program for
absence of immediate medical attention to result in any                  people 65 years of age or older, some people under age
of the following:                                                        65 with certain disabilities, and people with end-stage
• Placing the person's health (or, with respect to a                     renal disease (generally those with permanent kidney
  pregnant woman, the health of the woman or her                         failure who need dialysis or a kidney transplant). In this
  unborn child) in serious jeopardy                                      Membership Agreement and Evidence of Coverage,
                                                                         Members who are "eligible for" Medicare Part A or B are
• Serious impairment to bodily functions                                 those who would qualify for Medicare Part A or B
• Serious dysfunction of any bodily organ or part                        coverage if they applied for it. Members who "have"
                                                                         Medicare Part A or B are those who have been granted
A mental health condition is an Emergency Medical                        Medicare Part A or B coverage.
Condition when it meets the requirements of the                          Member: A person who is eligible and enrolled under
paragraph above, or when the condition manifests itself                  this Membership Agreement and Evidence of Coverage,
by acute symptoms of sufficient severity such that either                and for whom we have received applicable Premiums.
of the following is true:                                                This Membership Agreement and Evidence of Coverage
• The person is an immediate danger to himself or                        sometimes refers to a Member as "you."
  herself or to others                                                   Membership Agreement and Evidence of Coverage:
• The person is immediately unable to provide for, or                    This Membership Agreement and Disclosure Form and
  use, food, shelter, or clothing, due to the mental                     Evidence of Coverage document, which describes your
  disorder                                                               Health Plan coverage. This Membership Agreement and
                                                                         Evidence of Coverage, the Rate Sheet which is
Emergency Services: All of the following with respect
                                                                         incorporated into this Membership Agreement and
to an Emergency Medical Condition:
                                                                         Evidence of Coverage by reference, and any
• A medical screening exam that is within the                            amendments, constitute the legally binding contract
  capability of the emergency department of a hospital,                  between Health Plan and the Subscriber.
  including ancillary services (such as imaging and
                                                                         Non–Plan Hospital: A hospital other than a Plan
  laboratory Services) routinely available to the
                                                                         Hospital.
  emergency department to evaluate the Emergency
  Medical Condition                                                      Non–Plan Physician: A physician other than a Plan
• Within the capabilities of the staff and facilities                    Physician.
  available at the hospital, Medically Necessary                         Non–Plan Provider: A provider other than a Plan
  examination and treatment required to Stabilize the                    Provider.
  patient (once your condition is Stabilized, Services
  you receive are Post Stabilization Care and not                        Out-of-Area Urgent Care: Medically Necessary
  Emergency Services)                                                    Services to prevent serious deterioration of your (or your
                                                                         unborn child's) health resulting from an unforeseen
Family: A Subscriber and all of his or her Dependents.                   illness, unforeseen injury, or unforeseen complication of
Health Plan: Kaiser Foundation Health Plan, Inc., a                      an existing condition (including pregnancy) if all of the
California nonprofit corporation. This Membership                        following are true:
Agreement and Evidence of Coverage sometimes refers                      • You are temporarily outside our Service Area
to Health Plan as "we" or "us."
                                                                         • You reasonably believed that your (or your unborn
Kaiser Permanente: Kaiser Foundation Hospitals (a                          child's) health would seriously deteriorate if you
California nonprofit corporation), Health Plan, and the                    delayed treatment until you returned to our Service
Medical Group.                                                             Area
Medical Group: The Southern California Permanente                        Plan Facility: Any facility listed in the "Plan Facilities"
Medical Group, a for-profit professional partnership.                    section or in a Kaiser Permanente guidebook (Your
                                                                         Guidebook) for our Service Area, except that Plan



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 5
Facilities are subject to change at any time without              Rate Sheet: The document that lists premiums for the
notice. For the current locations of Plan Facilities, please      "Kaiser Permanente Individual—Conversion Plan." The
call our Member Service Call Center.                              Premium for your coverage under this Membership
                                                                  Agreement and Evidence of Coverage is listed in the
Plan Hospital: Any hospital listed in the "Plan
                                                                  Rate Sheet included with the Subscriber's acceptance
Facilities" section or in a Kaiser Permanente guidebook
                                                                  letter, unless the Rate Sheet has been amended as
(Your Guidebook) for our Service Area, except that Plan
                                                                  described under "Term and amendment of this
Hospitals are subject to change at any time without
                                                                  Membership Agreement and Evidence of Coverage" in
notice. For the current locations of Plan Hospitals, please
                                                                  the "Introduction" section.
call our Member Service Call Center.
                                                                  Region: A Kaiser Foundation Health Plan organization
Plan Medical Office: Any medical office listed in the
                                                                  or allied plan that conducts a direct-service health care
"Plan Facilities" section or in a Kaiser Permanente
                                                                  program. For information about Region locations in the
guidebook (Your Guidebook) for our Service Area,
                                                                  District of Columbia and parts of Northern California,
except that Plan Medical Offices are subject to change at
                                                                  Colorado, Georgia, Hawaii, Idaho, Maryland, Ohio,
any time without notice. For the current locations of Plan
                                                                  Oregon, Virginia, and Washington, please call our
Medical Offices, please call our Member Service Call
                                                                  Member Service Call Center.
Center.
                                                                  Service Area: Orange County is entirely inside our
Plan Pharmacy: A pharmacy owned and operated by
                                                                  Service Area. Portions of the following counties are also
Kaiser Permanente or another pharmacy that we
                                                                  inside our Service Area, as indicated by the ZIP codes
designate. Please refer to Your Guidebook for a list of
                                                                  below for each county:
Plan Pharmacies in your area, except that Plan
Pharmacies are subject to change at any time without              • Imperial: 92274–75
notice. For the current locations of Plan Pharmacies,             • Kern: 93203, 93205–06, 93215–16, 93220, 93222,
please call our Member Service Call Center.                         93224–26, 93238, 93240–41, 93243, 93249–52,
Plan Physician: Any licensed physician who is a partner             93263, 93268, 93276, 93280, 93285, 93287, 93301–
or employee of the Medical Group, or any licensed                   09, 93311–14, 93380, 93383–90, 93501–02, 93504–
physician who contracts to provide Services to Members              05, 93518–19, 93531, 93536, 93560–61, 93581
(but not including physicians who contract only to                • Los Angeles: 90001–84, 90086–91, 90093–96,
provide referral Services).                                         90101, 90103, 90189, 90201–02, 90209–13, 90220–
Plan Provider: A Plan Hospital, a Plan Physician, the               24, 90230–33, 90239–42, 90245, 90247–51, 90254–
Medical Group, a Plan Pharmacy, or any other health                 55, 90260–67, 90270, 90272, 90274–75, 90277–78,
care provider that we designate as a Plan Provider.                 90280, 90290–96, 90301–12, 90401–11, 90501–10,
                                                                    90601–10, 90623, 90630–31, 90637–40, 90650–52,
Plan Skilled Nursing Facility: A Skilled Nursing                    90660–62, 90670–71, 90701–03, 90706–07, 90710–
Facility approved by Health Plan.                                   17, 90723, 90731–34, 90744–49, 90755, 90801–10,
Post-Stabilization Care: Medically Necessary Services               90813–15, 90822, 90831–35, 90840, 90842, 90844,
related to your Emergency Medical Condition that you                90846–48, 90853, 90895, 91001, 91003, 91006–12,
receive after your treating physician determines that this          91016–17, 91020–21, 91023–25, 91030–31, 91040–
condition is Stabilized.                                            43, 91046, 91066, 91077, 91101–10, 91114–18,
                                                                    91121, 91123–26, 91129, 91182, 91184–85, 91188–
Premiums: Periodic membership charges paid by or on                 89, 91199, 91201–10, 91214, 91221–22, 91224–26,
behalf of each Member. Premiums are in addition to any              91301–11, 91313, 91316, 91321–22, 91324–31,
Cost Sharing.                                                       91333–35, 91337, 91340–46, 91350–57, 91361–62,
Primary Care Physicians: Generalists in internal                    91364–65, 91367, 91371–72, 91376, 91380–81,
medicine, pediatrics, and family practice, and specialists          91383–87, 91390, 91392–96, 91401–13, 91416,
in obstetrics/gynecology whom the Medical Group                     91423, 91426, 91436, 91470, 91482, 91495–96,
designates as Primary Care Physicians. Please refer to              91499, 91501–08, 91510, 91521–23, 91601–12,
our website at kp.org for a directory of Primary Care               91614–18, 91702, 91706, 91709, 91711, 91714–16,
Physicians, except that the directory is subject to change          91722–24, 91731–35, 91740–41, 91744–50, 91754–
without notice. For the current list of physicians that are         56, 91765–73, 91775–76, 91778, 91780, 91788–93,
available as Primary Care Physicians, please call the               91795, 91801–04, 91896, 93243, 93510, 93532,
personal physician selection department at the phone                93534–36, 93539, 93543–44, 93550–53, 93560,
number listed in Your Guidebook.                                    93563, 93584, 93586, 93590–91, 93599




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 6
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Riverside: 91752, 92201–03, 92210–11, 92220,                           within another facility (for example, a hospital) as long
  92223, 92230, 92234–36, 92240–41, 92247–48,                            as it continues to meet this definition.
  92253–55, 92258, 92260–64, 92270, 92274, 92276,
                                                                         Spouse: The Subscriber's legal husband or wife. For the
  92282, 92292, 92320, 92324, 92373, 92399, 92501–
                                                                         purposes of this Membership Agreement and Evidence of
  09, 92513–19, 92521–22, 92530–32, 92543–46,
                                                                         Coverage, the term "Spouse" includes the Subscriber's
  92548, 92551–57, 92562–64, 92567, 92570–72,
                                                                         same-sex spouse if the Subscriber and spouse are a
  92581–87, 92589–93, 92595–96, 92599, 92860,
                                                                         couple who meet all of the requirements of Section
  92877–83
                                                                         308(c) of the California Family Code, the Subscriber's
• San Bernardino: 91701, 91708–10, 91729–30, 91737,                      registered domestic partner who meets all of the
  91739, 91743, 91758–59, 91761–64, 91766, 91784–                        requirements of Sections 297 or 299.2 of the California
  86, 91792, 92252, 92256, 92268, 92277–78, 92284–                       Family Code, or the Subscriber's domestic partner as
  86, 92305, 92307–08, 92313–18, 92321–22, 92324–                        determined by Health Plan.
  26, 92329, 92331, 92333–37, 92339–41, 92344–46,
                                                                         Stabilize: To provide the medical treatment of the
  92350, 92352, 92354, 92357–59, 92369, 92371–78,
                                                                         Emergency Medical Condition that is necessary to
  92382, 92385–86, 92391–95, 92397, 92399, 92401–
                                                                         assure, within reasonable medical probability, that no
  08, 92410–15, 92418, 92423–24, 92427, 92880
                                                                         material deterioration of the condition is likely to result
• San Diego: 91901–03, 91908–17, 91921, 91931–33,                        from or occur during the transfer of the person from the
  91935, 91941–47, 91950–51, 91962–63, 91976–80,                         facility. With respect to a pregnant woman who is having
  91987, 92003, 92007–11, 92013–14, 92018–30,                            contractions, when there is inadequate time to safely
  92033, 92037–40, 92046, 92049, 92051–52, 92054–                        transfer her to another hospital before delivery (or the
  61, 92064–65, 92067–69, 92071–72, 92074–75,                            transfer may pose a threat to the health or safety of the
  92078–79, 92081–86, 92088, 92091–93, 92096,                            woman or unborn child), "Stabilize" means to deliver
  92101–24, 92126–32, 92134–40, 92142–43, 92145,                         (including the placenta).
  92147, 92149–50, 92152–55, 92158–79, 92182,
  92184, 92186–87, 92190–99                                              Subscriber: A Member who is eligible for membership
                                                                         on his or her own behalf and not by virtue of Dependent
• Ventura: 90265, 91304, 91307, 91311, 91319–20,                         status and for whom we have received applicable
  91358–62, 91377, 93001–07, 93009–12, 93015–16,                         Premiums.
  93020–22, 93030–36, 93040–44, 93060–66, 93094,
  93099, 93252                                                           Urgent Care: Medically Necessary Services for a
                                                                         condition that requires prompt medical attention but is
For each ZIP code listed for a county, our Service Area                  not an Emergency Medical Condition.
includes only the part of that ZIP code that is in that
county. When a ZIP code spans more than one county,
the part of that ZIP code that is in another county is not
inside our Service Area, unless either (1) that other                   Premiums, Eligibility, and
county is entirely in our Service Area as listed above, or              Enrollment
(2) that other county is also listed above and that ZIP
code is also listed for that other county.
Note: We may expand our Service Area at any time by                     Premiums
giving written notice to the Subscriber. ZIP codes are                   You must prepay the Premiums listed on the Rate Sheet,
subject to change by the U.S. Postal Service.                            applicable to your coverage, for each month on or before
Services: Health care services or items ("health care"                   the last day of the preceding month. We may amend the
includes both physical health care and mental health                     Premiums listed on the Rate Sheet upon 30-days
care).                                                                   prior written notice, as described under "Term and
                                                                         amendment of this Membership Agreement and
Skilled Nursing Facility: A facility that provides                       Evidence of Coverage" in the "Introduction" section.
inpatient skilled nursing care, rehabilitation services, or              Also, your Premiums may change as follows:
other related health services and is licensed by the state
of California. The facility's primary business must be the               • When you move to a new rate area, any change in
provision of 24-hour-a-day licensed skilled nursing care.                  Premiums will take effect at the same time the change
The term "Skilled Nursing Facility" does not include                       in your coverage becomes effective
convalescent nursing homes, rest facilities, or facilities               • When the Subscriber progresses to a new age band,
for the aged, if those facilities furnish primarily custodial              any change in Premiums will take effect upon
care, including training in routines of daily living. A                    renewal
"Skilled Nursing Facility" may also be a unit or section


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 7
Only Members for whom we have received the                        If you live in or move to the service area of another
appropriate Premiums are entitled to coverage under this          Region after enrollment, you are not eligible for
Membership Agreement and Evidence of Coverage, and                membership under this Southern California Region
then only for the period for which we have received               Membership Agreement and Evidence of Coverage:
payment.                                                          • Regions outside California. If you move to the
                                                                    service area of a Region outside California, you may
If a government agency or other taxing authority imposes            be able to apply for membership in that Region by
or increases a tax or other charge (other than a tax on or          contacting the member or customer service
measured by net income) upon Health Plan or Plan                    department there, but the plan, including coverage,
Providers (or any of their activities), then upon 30-days           premiums, and eligibility requirements, might not be
prior written notice we may increase Premiums to                    the same. For the purposes of this eligibility rule, the
include your share of the new or increased tax or charge.           service areas of the Regions outside California may
Your share is determined by dividing the number of                  change on January 1 of each year and are currently
enrolled Members in your Family by the total number of              the District of Columbia and parts of Colorado,
Members enrolled in our Southern California Region.                 Georgia, Hawaii, Idaho, Maryland, Ohio, Oregon,
                                                                    Virginia, and Washington. For more information,
                                                                    please call our Member Service Call Center
Who Is Eligible
                                                                  • Northern California Region's service area. If you
To enroll and to continue enrollment, you must meet all             move to our Northern California Region's service
of the eligibility requirements described in this "Who Is           area, we will transfer your membership to the
Eligible" section.                                                  individual plan in that Region that is most similar to
                                                                    this plan. All terms and conditions in your application
Eligibility for conversion                                          for membership, including the Arbitration
The Subscriber and Dependents (except newborns, newly               Agreement, will continue to apply. We will provide
adopted children, and children placed with you or your              you with a Northern California Region membership
Spouse for adoption) must have been Members under                   agreement and evidence of coverage, the effective
one of our Group plans at the time of enrollment.                   date of coverage, and a Kaiser Permanente ID card
                                                                    with a new medical record number on it. Please refer
You may not convert to our Kaiser Permanente                        to the Rate Sheet for the premiums that apply in the
Individual—Conversion Plan if any of the following is               Northern California Region. For more information,
true:                                                               please call our Member Service Call Center
• You continue to be eligible for coverage through your
                                                                  If you move anywhere else outside our Service Area
  Group (but not counting COBRA, Cal-COBRA,
                                                                  after enrollment, you can continue your membership as
  USERRA, or State Continuation Coverage after
                                                                  long as you meet all other eligibility requirements.
  COBRA or Cal-COBRA coverage)
                                                                  However, you must receive covered Services from Plan
• Your membership ends because our Membership                     Providers inside our Service Area, except as described in
  Agreement and Evidence of Coverage with your                    the sections listed below for the following Services:
  Group terminates and it is replaced by another plan
                                                                  • Authorized referrals as described under "Getting a
  within 15 days of the termination date
                                                                    Referral" in the "How to Obtain Services" section
• We terminated your membership under "Termination
                                                                  • Emergency ambulance Services as described under
  for Cause" in the "Termination of Membership"
                                                                    "Ambulance Services" in the "Benefits and Cost
  section
                                                                    Sharing" section
• You live in the service area of a Region outside
                                                                  • Emergency Services, Post-Stabilization Care, and
  California, except otherwise-eligible Dependent
                                                                    Out-of-Area Urgent Care as described in the
  children of the Subscriber or of the Subscriber's
                                                                    "Emergency Services and Urgent Care" section
  Spouse are not ineligible to be covered Dependents
  solely because they live in a Region outside                    • Hospice care as described under "Hospice Care" in
  California                                                        the "Benefits and Cost Sharing" section

Service Area eligibility requirements                             Members with Medicare
The "Definitions" section describes our Service Area and          This Membership Agreement and Evidence of Coverage
how it may change.                                                is not intended for most Medicare beneficiaries. If,
                                                                  during the term of this Membership Agreement and



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 8
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
Evidence of Coverage, you are (or become) eligible for                   your first payment to us will include coverage from when
Medicare (please see "Medicare" in the "Definitions"                     your Group coverage ended through our current billing
section for the meaning of "eligible for" Medicare) you                  cycle. If you do not send us the Premium payment by the
may enroll in Kaiser Permanente Senior Advantage if                      due date on the bill, you will not be enrolled in our
you are eligible to enroll in the plan and the plan is                   Kaiser Permanente Individual—Conversion Plan.
available to you.
                                                                         Changing your benefit plan
Capacity limit. You may be ineligible to enroll in Kaiser                If you choose the Deductible 30/1500 Plan, you cannot
Permanente Senior Advantage if that plan has reached a                   change to the Copayment 25 Plan later unless you
capacity limit that the Centers for Medicare & Medicaid                  request it within 30 days of your effective date of
Services has approved. This limitation does not apply if                 coverage under the Deductible 30/1500 Plan. If you
you are currently a Health Plan Member in the Northern                   choose the Copayment 25 Plan, you can change to the
California or Southern California Region who is eligible                 Deductible 30/1500 Plan at any time.
for Medicare (for example, when you turn age 65).
                                                                         Effective date of coverage
Medicare late enrollment penalties. If you become                        If we approve your enrollment application, coverage will
eligible for Medicare Part B and do not enroll, Medicare                 begin on the date your Group coverage ends, without
may require you to pay a late enrollment penalty if you                  lapse.
later enroll in Medicare Part B. However, if you delay
enrollment in Part B because you or your husband or
wife are still working and have coverage through an
employer group health plan, you may not have to pay the                 How to Obtain Services
penalty. Also, if you are (or become) eligible for
Medicare and go without creditable prescription drug                     As a Member, you are selecting our medical care
coverage (drug coverage that is at least as good as the                  program to provide your health care. You must receive
standard Medicare Part D prescription drug coverage) for                 all covered care from Plan Providers inside our Service
a continuous period of 63 days or more, you may have to                  Area, except as described in the sections listed below for
pay a late enrollment penalty if you later sign up for                   the following Services:
Medicare prescription drug coverage. If you are (or                      • Authorized referrals as described under "Getting a
become) eligible for Medicare, we will send you a notice                   Referral" in this "How to Obtain Services" section
that tells you whether your drug coverage under this
Membership Agreement and Evidence of Coverage is                         • Emergency ambulance Services as described under
creditable prescription drug coverage at the times                         "Ambulance Services" in the "Benefits and Cost
required by the Centers for Medicare & Medicaid                            Sharing" section
Services and upon your request. For more information,                    • Emergency Services, Post-Stabilization Care, and
contact our Member Service Call Center.                                    Out-of-Area Urgent Care as described in the
                                                                           "Emergency Services and Urgent Care" section

How to Enroll                                                            • Hospice care as described under "Hospice Care" in
                                                                           the "Benefits and Cost Sharing" section
This plan does not include dependent coverage, so each
person in your family who is accepted for coverage must                  Our medical care program gives you access to all of the
enroll as a Subscriber under his or her own Membership                   covered Services you may need, such as routine care
Agreement and Evidence of Coverage.                                      with your own personal Plan Physician, hospital care,
                                                                         laboratory and pharmacy Services, Emergency Services,
We must receive your application within 63 days of the                   Urgent Care, and other benefits described in the
date of our termination letter, or your membership                       "Benefits and Cost Sharing" section.
termination date, whichever date is later. To request an
application, please call our Member Service Call Center.
                                                                        Routine Care
If we approve your enrollment application, we will send
                                                                         If you need the following Services, you should schedule
you billing information within 30 days after we receive
                                                                         an appointment:
your application. You will have 45 days to pay the bill.
Because your coverage under our Kaiser Permanente                        • Preventive care (Services that protect against disease,
Individual—Conversion Plan begins when your Group                          promote health, or detect disease at its earliest stages
coverage ends (including Group continuation coverage),                     before noticeable symptoms develop)



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 9
• Periodic follow-up care (regularly scheduled follow-            We encourage you to choose a personal Plan Physician.
  up care, such as visits to monitor a chronic condition)         You may choose any available personal Plan Physician.
                                                                  Parents may choose a pediatrician as the personal Plan
• Other care that is not Urgent Care
                                                                  Physician for their child. Most personal Plan Physicians
                                                                  are Primary Care Physicians (generalists in internal
To make a non-urgent appointment, please refer to Your
                                                                  medicine, pediatrics, or family practice, or specialists in
Guidebook for appointment telephone numbers, or go to
                                                                  obstetrics/gynecology whom the Medical Group
our website at kp.org to request an appointment online.
                                                                  designates as Primary Care Physicians). Some specialists
                                                                  who are not designated as Primary Care Physicians but
Urgent Care                                                       who also provide primary care may be available as
                                                                  personal Plan Physicians. For example, some specialists
An Urgent Care need is one that requires prompt medical           in internal medicine and obstetrics/gynecology who are
attention but is not an Emergency Medical Condition. If           not designated as Primary Care Physicians may be
you think you may need Urgent Care, call the                      available as personal Plan Physicians.
appropriate appointment or advice telephone number at a
Plan Facility. Please refer to Your Guidebook for                 To learn how to select a personal Plan Physician, please
appointment and advice telephone numbers.                         refer to Your Guidebook or call our Member Service Call
                                                                  Center. You can find a directory of our Plan Physicians
For information about Out-of-Area Urgent Care, please             on our website at kp.org. For the current list of
refer to "Urgent Care" in the "Emergency Services and             physicians that are available as Primary Care Physicians,
Urgent Care" section.                                             please call the personal physician selection department at
                                                                  the phone number listed in Your Guidebook. You can
                                                                  change your personal Plan Physician for any reason.
Not Sure What Kind of Care You Need?
Sometimes it's difficult to know what kind of care you            Getting a Referral
need, so we have licensed health care professionals
available to assist you by phone 24 hours a day, seven            Referrals to Plan Providers
days a week. Here are some of the ways they can help              A Plan Physician must refer you before you can receive
you:                                                              care from specialists, such as specialists in surgery,
                                                                  orthopedics, cardiology, oncology, urology,
• They can answer questions about a health concern,
                                                                  dermatology, and physical, occupational, and speech
  and instruct you on self-care at home if appropriate
                                                                  therapies. However, you do not need a referral or prior
• They can advise you about whether you should get                authorization to receive care from any of the following:
  medical care, and how and where to get care (for
                                                                  • Your personal Plan Physician
  example, if you are not sure whether your condition is
  an Emergency Medical Condition, they can help you               • Generalists in internal medicine, pediatrics, and
  decide whether you need Emergency Services or                     family practice
  Urgent Care, and how and where to get that care)                • Specialists in optometry, psychiatry, chemical
• They can tell you what to do if you need care and a               dependency, and obstetrics/gynecology
  Plan Medical Office is closed
                                                                  Although a referral or prior authorization is not required
You can reach one of these licensed health care                   to receive care from these providers, the provider may
professionals by calling the appointment or advice                have to get prior authorization for certain Services in
telephone number listed in Your Guidebook. When you               accord with "Medical Group authorization procedure for
call, a trained support person may ask you questions to           certain referrals" in this "Getting a Referral" section.
help determine how to direct your call.
                                                                  Medical Group authorization procedure for
                                                                  certain referrals
Your Personal Plan Physician                                      The following Services require prior authorization by the
                                                                  Medical Group for the Services to be covered ("prior
Personal Plan Physicians provide primary care and play
                                                                  authorization" means that the Medical Group must
an important role in coordinating care, including hospital
                                                                  approve the Services in advance):
stays and referrals to specialists.
                                                                  • Durable medical equipment. If your Plan Physician
                                                                    prescribes durable medical equipment, he or she will



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 10
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   submit a written referral to the Plan Hospital's durable                 Group will refer you to physician(s) at a transplant
   medical equipment coordinator, who will authorize                        center, and the Medical Group will authorize the
   the durable medical equipment if he or she                               Services if the transplant center's physician(s)
   determines that your durable medical equipment                           determine that they are Medically Necessary. Note: A
   coverage includes the item and that the item is listed                   Plan Physician may provide or authorize a corneal
   on our formulary for your condition. If the item                         transplant without using this Medical Group
   doesn't appear to meet our durable medical equipment                     transplant authorization procedure
   formulary guidelines, then the durable medical
   equipment coordinator will contact the Plan Physician                 Decisions regarding requests for authorization will be
   for additional information. If the durable medical                    made only by licensed physicians or other appropriately
   equipment request still doesn't appear to meet our                    licensed medical professionals.
   durable medical equipment formulary guidelines, it
   will be submitted to the Medical Group's designee                     Medical Group's decision time frames. The applicable
   Plan Physician, who will authorize the item if he or                  Medical Group designee will make the authorization
   she determines that it is Medically Necessary. For                    decision within the time frame appropriate for your
   more information about our durable medical                            condition, but no later than five business days after
   equipment formulary, please refer to "Durable                         receiving all the information (including additional
   Medical Equipment for Home Use" in the "Benefits                      examination and test results) reasonably necessary to
   and Cost Sharing" section                                             make the decision, except that decisions about urgent
• Ostomy and urological supplies. If your Plan                           Services will be made no later than 72 hours after receipt
  Physician prescribes ostomy or urological supplies,                    of the information reasonably necessary to make the
  he or she will submit a written referral to the Plan                   decision. If the Medical Group needs more time to make
  Hospital's designated coordinator, who will authorize                  the decision because it doesn't have information
  the item if he or she determines that it is covered and                reasonably necessary to make the decision, or because it
  the item is listed on our soft goods formulary for your                has requested consultation by a particular specialist, you
  condition. If the item doesn't appear to meet our soft                 and your treating physician will be informed about the
  goods formulary guidelines, then the coordinator will                  additional information, testing, or specialist that is
  contact the Plan Physician for additional information.                 needed, and the date that the Medical Group expects to
  If the request still doesn't appear to meet our soft                   make a decision.
  goods formulary guidelines, it will be submitted to
  the Medical Group's designee Plan Physician, who                       Your treating physician will be informed of the decision
  will authorize the item if he or she determines that it                within 24 hours after the decision is made. If the Services
  is Medically Necessary. For more information about                     are authorized, your physician will be informed of the
  our soft goods formulary, please refer to "Ostomy and                  scope of the authorized Services. If the Medical Group
  Urological Supplies" in the "Benefits and Cost                         does not authorize all of the Services, Health Plan will
  Sharing" section                                                       send you a written decision and explanation within two
                                                                         business days after the decision is made. The letter will
• Services not available from Plan Providers. If your
                                                                         include information about your appeal rights, which are
  Plan Physician decides that you require covered
                                                                         described in the "Dispute Resolution" section. Any
  Services not available from Plan Providers, he or she
                                                                         written criteria that the Medical Group uses to make the
  will recommend to the Medical Group that you be
                                                                         decision to authorize, modify, delay, or deny the request
  referred to a Non–Plan Provider inside or outside our
                                                                         for authorization will be made available to you upon
  Service Area. The appropriate Medical Group
                                                                         request.
  designee will authorize the Services if he or she
  determines that they are Medically Necessary and are
                                                                         Cost Sharing. The Cost Sharing for these referral
  not available from a Plan Provider. Referrals to Non–
                                                                         Services is the Cost Sharing required for Services
  Plan Physicians will be for a specific treatment plan,
                                                                         provided by a Plan Provider as described in the "Benefits
  which may include a standing referral if ongoing care
                                                                         and Cost Sharing" section.
  is prescribed. Please ask your Plan Physician what
  Services have been authorized
                                                                         More information. This description is only a brief
• Transplants. If your Plan Physician makes a written                    summary of the authorization procedure. The policies
  referral for a transplant, the Medical Group's regional                and procedures (including a description of the
  transplant advisory committee or board (if one exists)                 authorization procedure or information about the
  will authorize the Services if it determines that they                 authorization procedure applicable to some Plan
  are Medically Necessary. In cases where no                             Providers other than Kaiser Foundation Hospitals and the
  transplant committee or board exists, the Medical                      Medical Group) are available upon request from our


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 11
Member Service Call Center. Please refer to "Post-                for service, and incentive payments. To learn more about
Stabilization Care" under "Emergency Services" in the             how Plan Physicians are paid to provide or arrange
"Emergency Services and Urgent Care" section for                  medical and hospital care for Members, please ask your
authorization requirements that apply to Post-                    Plan Physician or call our Member Service Call Center.
Stabilization Care from Non–Plan Providers.
                                                                  Financial liability
                                                                  Our contracts with Plan Providers provide that you are
Second Opinions                                                   not liable for any amounts we owe. However, you may
                                                                  be liable for the full price of noncovered Services you
If you request a second opinion, it will be provided to
                                                                  obtain from Plan Providers or Non–Plan Providers.
you when Medically Necessary by an appropriately
qualified medical professional. This is a physician who is
                                                                  Breach of contract
acting within his or her scope of practice and who
possesses a clinical background related to the illness or         We will give you written notice within a reasonable time
condition associated with the request for a second                if any contracted provider breaches a contract with us, or
medical opinion. Here are some examples of when a                 is not able to provide contracted Services, if you might
second opinion is Medically Necessary:                            be materially and adversely affected.

• Your Plan Physician has recommended a procedure                 Termination of a Plan Provider's contract and
  and you are unsure about whether the procedure is               completion of Services
  reasonable or necessary
                                                                  If our contract with any Plan Provider terminates while
• You question a diagnosis or plan of care for a                  you are under the care of that provider, we will retain
  condition that threatens substantial impairment or loss         financial responsibility for covered care you receive from
  of life, limb, or bodily functions                              that provider until we make arrangements for the
• The clinical indications are not clear or are complex           Services to be provided by another Plan Provider and
  and confusing                                                   notify you of the arrangements. We will give you 60
                                                                  days prior written notice (or as soon as reasonably
• A diagnosis is in doubt due to conflicting test results         possible) if a contracted provider group or hospital
• The Plan Physician is unable to diagnose the                    terminates a contract with us and you might be materially
  condition                                                       and adversely affected.
• The treatment plan in progress is not improving your
  medical condition within an appropriate period of               In addition, if you are currently receiving covered
  time, given the diagnosis and plan of care                      Services in one of the following cases from a Plan
                                                                  Hospital or a Plan Physician (or certain other providers)
• You have concerns about the diagnosis or plan of care           when our contract with the provider ends (for reasons
                                                                  other than medical disciplinary cause or criminal
You can either ask your Plan Physician to help you                activity), you may be eligible for limited coverage of that
arrange for a second medical opinion, or you can make             terminated provider's Services:
an appointment with another Plan Physician. If the
                                                                  • Acute conditions, which are medical conditions that
Medical Group determines that there isn't a Plan
                                                                    involve a sudden onset of symptoms due to an illness,
Physician who is an appropriately qualified medical
                                                                    injury, or other medical problem that requires prompt
professional for your condition, the Medical Group will
                                                                    medical attention and has a limited duration. We may
authorize a referral to a Non–Plan Physician for a
                                                                    cover these Services until the acute condition ends
Medically Necessary second opinion.
                                                                  • We may cover Services for serious chronic conditions
Cost Sharing. The Cost Sharing for these referral                   until the earlier of (1) 12 months from the termination
Services is the Cost Sharing required for Services                  date of the terminated provider, or (2) the first day
provided by a Plan Provider as described in the "Benefits           after a course of treatment is complete when it would
and Cost Sharing" section.                                          be safe to transfer your care to a Plan Provider, as
                                                                    determined by Kaiser Permanente after consultation
                                                                    with the Member and Non–Plan Provider and
Contracts with Plan Providers                                       consistent with good professional practice. Serious
                                                                    chronic conditions are illnesses or other medical
How Plan Providers are paid                                         conditions that are serious, if one of the following is
Health Plan and Plan Providers are independent                      true about the condition:
contractors. Plan Providers are paid in a number of ways,           ♦ it persists without full cure
such as salary, capitation, per diem rates, case rates, fee


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 12
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   ♦ it worsens over an extended period of time                         Visiting Other Regions
   ♦ it requires ongoing treatment to maintain
       remission or prevent deterioration                                If you visit the service area of another Region
                                                                         temporarily (not more than 90 days), you can receive
• Pregnancy and immediate postpartum care. We may                        visiting member care from designated providers in that
  cover these Services for the duration of the pregnancy                 area. Visiting member care is described in our visiting
  and immediate postpartum care                                          member brochure. Visiting member care and your out-
• Terminal illnesses, which are incurable or irreversible                of-pocket costs may differ from the covered Services and
  illnesses that have a high probability of causing death                Cost Sharing described in this Membership Agreement
  within a year or less. We may cover completion of                      and Evidence of Coverage.
  these Services for the duration of the illness
• Care for children under age 3. We may cover                            The 90-day limit on visiting member care does not apply
  completion of these Services until the earlier of (1) 12               to a Dependent child who attends an accredited college
  months from the termination date of the terminated                     or accredited vocational school. The service areas and
  provider, or (2) the child's third birthday                            facilities where you may obtain visiting member care
                                                                         may change at any time without notice.
• Surgery or another procedure that is documented as
  part of a course of treatment and has been                             Please call our Member Service Call Center for more
  recommended and documented by the provider to                          information about visiting member care, including
  occur within 180 days of the termination date of the                   facility locations in the service area of another Region,
  terminated provider                                                    and to request a copy of the visiting member brochure.

To qualify for this completion of Services coverage, all
of the following requirements must be met:                              Your ID Card
• Your Health Plan coverage is in effect on the date
                                                                         Each Member's Kaiser Permanente ID card has a medical
  you receive the Service
                                                                         record number on it, which you will need when you call
• You are receiving Services in one of the cases listed                  for advice, make an appointment, or go to a provider for
  above from the terminated Plan Provider on the                         covered care. When you get care, please bring your
  provider's termination date                                            Kaiser Permanente ID card and a photo ID. Your
• The provider agrees to our standard contractual terms                  medical record number is used to identify your medical
  and conditions, such as conditions pertaining to                       records and membership information. Your medical
  payment and to providing Services inside our Service                   record number should never change. Please call our
  Area                                                                   Member Service Call Center if we ever inadvertently
                                                                         issue you more than one medical record number or if you
• The Services to be provided to you would be covered                    need to replace your Kaiser Permanente ID card.
  Services under this Membership Agreement and
  Evidence of Coverage if provided by a Plan Provider                    Your ID card is for identification only. To receive
• You request completion of Services within 30 days                      covered Services, you must be a current Member.
  (or as soon as reasonably possible) from the                           Anyone who is not a Member will be billed as a non-
  termination date of the Plan Provider                                  Member for any Services he or she receives. If you let
                                                                         someone else use your ID card, we may keep your ID
Cost Sharing. The Cost Sharing for completion of                         card and terminate your membership as described under
Services is the Cost Sharing required for Services                       "Termination for Cause" in the "Termination of
provided by a Plan Provider as described in the "Benefits                Membership" section.
and Cost Sharing" section.

More information. For more information about this                       Getting Assistance
provision, or to request the Services or a copy of our
                                                                         We want you to be satisfied with the health care you
"Completion of Covered Services" policy, please call our                 receive from Kaiser Permanente. If you have any
Member Service Call Center.                                              questions or concerns, please discuss them with your
                                                                         personal Plan Physician or with other Plan Providers
                                                                         who are treating you. They are committed to your
                                                                         satisfaction and want to help you with your questions.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 13
Member Services                                                      Guidebook (please refer to Your Guidebook for
Most Plan Facilities have an office staffed with                     Emergency Department locations in your area)
representatives who can provide assistance if you need            • Same-day Urgent Care appointments are available at
help obtaining Services. At different locations, these              many locations (please refer to Your Guidebook for
offices may be called Member Services, Patient                      Urgent Care locations in your area)
Assistance, or Customer Service. In addition, our
Member Service Call Center representatives are                    • Many Plan Medical Offices have evening and
available to assist you weekdays from 7 a.m. to 7 p.m.              weekend appointments
and weekends from 7 a.m. to 3 p.m. (except holidays)              • Many Plan Facilities have a Member Services
toll free at 1-800-464-4000 or 1-800-777-1370 (TTY for              Department (refer to Your Guidebook for locations in
the deaf, hard of hearing, or speech impaired). For your            your area)
convenience, you can also contact us through our website
at kp.org.
                                                                  Plan Hospitals and Plan Medical Offices
Member Services representatives at our Plan Facilities
                                                                  The following is a list of Plan Hospitals and most Plan
and Member Service Call Center can answer any
                                                                  Medical Offices in our Service Area. Please refer to Your
questions you have about your benefits, available
                                                                  Guidebook for the types of covered Services that are
Services, and the facilities where you can receive care.
                                                                  available from each Plan Facility in your area, because
For example, they can explain your Health Plan benefits,
                                                                  some facilities provide only specific types of covered
how to make your first medical appointment, what to do
                                                                  Services. Additional Plan Medical Offices are listed in
if you move, what to do if you need care while you are
                                                                  Your Guidebook and on our website at kp.org. This list
traveling, and how to replace your ID card. These
                                                                  is subject to change at any time without notice. If you
representatives can also help you if you need to file a
                                                                  have any questions about the current locations of Plan
claim as described in the "Emergency Services and
                                                                  Facilities, please call our Member Service Call Center.
Urgent Care" section or with any issues as described in
the "Dispute Resolution" section.                                 Aliso Viejo
If you have questions about a bill or about how much              • Medical Offices: 24502 Pacific Park Dr.
you have paid toward your Deductible, or to get an
estimate of Charges for Services that are subject to the          Anaheim
Deductible, please call our Member Service Call Center            • Hospital and Medical Offices: 441 N. Lakeview Ave.
weekdays from 8 a.m. to 7 p.m. toll free at
1-800-390-3507. You can also get an estimate of                   • Medical Offices: 411 N. Lakeview Ave., 5475 E.
Charges for Services through our website at kp.org.                 La Palma Ave., and 1188 N. Euclid St.
                                                                  Bakersfield
Interpreter services
                                                                  • Hospital: 2615 Chester Ave.
If you need interpreter services when you call us or when           (San Joaquin Community Hospital)
you get covered Services, please let us know. Interpreter
services are available 24 hours a day, seven days a week,         • Medical Offices: 1200 Discovery Dr.,
at no cost to you. For more information on the interpreter          3501 Stockdale Hwy., 3700 Mall View Rd.,
services we offer, please call our Member Service Call              4801 Coffee Rd., and 8800 Ming Ave.
Center.                                                           Baldwin Park
                                                                  • Hospital and Medical Offices: 1011 Baldwin Park
                                                                    Blvd.
Plan Facilities                                                   Bellflower

At most of our Plan Facilities, you can usually receive all       • Medical Offices: 9400 E. Rosecrans Ave.
of the covered Services you need, including specialty             Bonita
care, pharmacy, and lab work. You are not restricted to a
particular Plan Facility, and we encourage you to use the         • Medical Offices: 3955 Bonita Rd.
facility that will be most convenient for you:                    Brea
• All Plan Hospitals provide inpatient Services and are           • Medical Offices: 1900 E. Lambert Rd.
  open 24 hours a day, seven days a week
                                                                  Camarillo
• Emergency Services are available from Plan Hospital
  Emergency Departments as described in Your                      • Medical Offices: 2620 E. Las Posas Rd.



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                         Page 14
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Carlsbad                                                                 Indio
• Medical Offices: 6860 Avenida Encinas                                  • Hospital: 47111 Monroe St. (John F.
                                                                           Kennedy Memorial Hospital)
Chino
                                                                         • Medical Offices: 81-719 Doctor Carreon Blvd.
• Medical Offices: 11911 Central Ave.
                                                                         Inglewood
Claremont
                                                                         • Medical Offices: 110 N. La Brea Ave.
• Medical Offices: 250 W. San Jose St.
                                                                         Irvine
Colton
                                                                         • Hospital and Medical Offices: 6640 Alton Pkwy.
• Medical Offices: 789 S. Cooley Dr.
                                                                         • Medical Offices: 6 Willard St.
Corona
                                                                         Joshua Tree
• Medical Offices: 2055 Kellogg Ave.
                                                                         • Hospital: 6601 White Feather Rd. (Hi-
Cudahy                                                                     Desert Medical Center)
• Medical Offices: 7825 Atlantic Ave.                                    • Please refer to Your Guidebook for other Plan
Culver City                                                                Providers in the Yucca Valley–Twentynine Palms
                                                                           area
• Medical Offices: 5620 Mesmer Ave.
                                                                         La Mesa
Diamond Bar
                                                                         • Medical Offices: 8080 Parkway Dr. and
• Medical Offices: 1336 Bridge Gate Dr.
                                                                           3875 Avocado Blvd.
Downey
                                                                         La Palma
• Hospital: 9333 E. Imperial Hwy.
                                                                         • Medical Offices: 5 Centerpointe Dr.
• Medical Offices: 9449 E. Imperial Hwy.
                                                                         Lancaster
El Cajon
                                                                         • Hospitals: 1600 W. Avenue J
• Medical Offices: 1630 E. Main St.                                        (Antelope Valley Hospital) and 43830 N. 10th St. W.
Escondido                                                                  (Lancaster Community Hospital)*
                                                                            * This hospital is expected to close in 2011 (upon
• Hospital: 555 E. Valley Pkwy.
                                                                              closure of this facility, it will no longer be a Plan
  (Palomar Medical Center)
                                                                              Hospital)
• Medical Offices: 732 N. Broadway St.
                                                                         • Medical Offices: 43112 N. 15th St. W.
Fontana
                                                                         Long Beach
• Hospital and Medical Offices: 9961 Sierra Ave.
                                                                         • Medical Offices: 3900 E. Pacific Coast Hwy.
Garden Grove
                                                                         Los Angeles
• Medical Offices: 12100 Euclid St.
                                                                         • Hospitals and Medical Offices: 1526 N. Edgemont St.
Gardena                                                                    and 6041 Cadillac Ave.
• Medical Offices: 15446 S. Western Ave.                                 • Medical Offices: 5119 E. Pomona Blvd. and
Glendale                                                                   12001 W. Washington Blvd.
• Medical Offices: 444 W. Glenoaks Blvd.                                 Lynwood
Harbor City                                                              • Medical Offices: 3840 Martin Luther King Jr. Blvd.
• Hospital and Medical Offices: 25825 S. Vermont                         Mission Hills
  Ave.                                                                   • Medical Offices: 11001 Sepulveda Blvd.
Huntington Beach                                                         Mission Viejo
• Medical Offices: 18081 Beach Blvd.                                     • Medical Offices: 23781 Maquina Ave.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 15
Montebello                                                        San Dimas
• Medical Offices: 1550 Town Center Dr.                           • Medical Offices: 1255 W. Arrow Hwy.
Moreno Valley                                                     San Juan Capistrano
• Hospital: 27300 Iris Ave.                                       • Medical Offices: 30400 Camino Capistrano
  (Moreno Valley Community Hospital)
                                                                  San Marcos
• Medical Offices: 12815 Heacock St.
                                                                  • Medical Offices: 400 Craven Rd.
Murrieta
                                                                  Santa Ana
• Hospital: 25500 Medical Center Dr.
                                                                  • Medical Offices: 3401 S. Harbor Blvd. and 1900 E.
  (Rancho Springs Medical Center)
                                                                    4th St.
Oceanside
                                                                  Santa Clarita
• Medical Offices: 3609 Ocean Ranch Blvd.
                                                                  • Medical Offices: 27107 Tourney Rd.
Ontario
                                                                  Simi Valley
• Medical Offices: 2295 S. Vineyard Ave.
                                                                  • Medical Offices: 3900 Alamo St.
Oxnard
                                                                  Temecula
• Medical Offices: 2200 E. Gonzales Rd.
                                                                  • Medical Offices: 27309 Madison Ave.
Palm Desert
                                                                  Thousand Oaks
• Medical Offices: 75-036 Gerald Ford Dr.
                                                                  • Medical Offices: 365 E. Hillcrest Dr. and
Palm Springs                                                        145 Hodencamp Rd.
• Hospital: 1150 N. Indian Canyon Dr.                             Torrance
  (Desert Regional Medical Center)
                                                                  • Medical Offices: 20790 Madrona Ave.
• Medical Offices: 1100 N. Palm Canyon Dr.
                                                                  Upland
Palmdale
                                                                  • Medical Offices: 1183 E. Foothill Blvd.
• Medical Offices: 4502 E. Avenue S
                                                                  Ventura
Panorama City
                                                                  • Hospital: 147 N. Brent St. (Community Memorial
• Hospital and Medical Offices: 13652 Cantara St.                   Hospital of San Buenaventura)
Pasadena                                                          • Medical Offices: 888 S. Hill Rd.
• Medical Offices: 3280 E. Foothill Blvd.                         Victorville
Rancho Cucamonga                                                  • Medical Offices: 14011 Park Ave.
• Medical Offices: 10850 Arrow Rte.                               West Covina
Redlands                                                          • Medical Offices: 1249 Sunset Ave.
• Medical Offices: 1301 California St.                            Whittier
Riverside                                                         • Medical Offices: 12470 Whittier Blvd.
• Hospital and Medical Offices: 10800 Magnolia Ave.               Wildomar
San Bernardino                                                    • Hospital: 36485 Inland Valley Dr.
• Medical Offices: 1717 Date Pl.                                    (Inland Valley Medical Center)
                                                                  • Medical Offices: 36450 Inland Valley Dr.
San Diego
• Hospital and Medical Offices: 4647 Zion Ave.                    Woodland Hills

• Medical Offices: 3250 Wing St., 4405 Vandever                   • Hospital and Medical Offices: 5601 De Soto Ave.
  Ave., 4650 Palm Ave., 7060 Clairemont Mesa Blvd.,               • Medical Offices: 21263 Erwin St.
  and 11939 Rancho Bernardo Rd.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                        Page 16
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Yorba Linda                                                              Services you receive from Plan Providers or Non–Plan
• Medical Offices: 22550 E. Savi Ranch Pkwy.                             Providers anywhere in the world as long as the Services
                                                                         would have been covered under the "Benefits and Cost
                                                                         Sharing" section (subject to the "Exclusions, Limitations,
Note: State law requires evidence of coverage documents
                                                                         Coordination of Benefits, and Reductions" section) if
to include the following notice: "Some hospitals and
                                                                         you had received them from Plan Providers.
other providers do not provide one or more of the
following services that may be covered under your plan
contract and that you or your family member might need:                  Emergency Services are available from Plan Hospital
family planning; contraceptive services, including                       Emergency Departments 24 hours a day, seven days a
emergency contraception; sterilization, including tubal                  week.
ligation at the time of labor and delivery; infertility
treatments; or abortion. You should obtain more                          Post-Stabilization Care
information before you enroll. Call your prospective                     Post-Stabilization Care is Medically Necessary Services
doctor, medical group, independent practice association,                 related to your Emergency Medical Condition that you
or clinic, or call the Kaiser Permanente Member Service                  receive after your treating physician determines that this
Call Center, to ensure that you can obtain the health care               condition is Stabilized. We cover Post-Stabilization Care
services that you need."                                                 from a Non–Plan Provider, including inpatient care at a
                                                                         Non–Plan Hospital, only if we provide prior
Please be aware that if a Service is covered but not                     authorization for the care or if otherwise required by
available at a particular Plan Facility, we will make it                 applicable law ("prior authorization" means that we must
available to you at another facility.                                    approve the Services in advance).

                                                                         To request authorization to receive Post-Stabilization
Your Guidebook to Kaiser Permanente                                      Care from a Non–Plan Provider, you must call us toll
Services (Your Guidebook)                                                free at 1-800-225-8883 (TTY users call 711) or the
                                                                         notification telephone number on your Kaiser
Plan Medical Offices and Plan Hospitals for your area                    Permanente ID card before you receive the care if it is
are listed in greater detail in Your Guidebook to Kaiser                 reasonably possible to do so (otherwise, call us as soon
Permanente Services (Your Guidebook). Your Guidebook                     as reasonably possible). After we are notified, we will
describes the types of covered Services that are available               discuss your condition with the Non–Plan Provider. If we
from each Plan Facility in your area, because some                       decide that you require Post-Stabilization Care and that
facilities provide only specific types of covered Services.              this care would be covered if you received it from a Plan
It includes additional facilities that are not listed in this            Provider, we will authorize your care from the Non–Plan
"Plan Facilities" section. Also, it explains how to use our              Provider or arrange to have a Plan Provider (or other
Services and make appointments, lists hours of                           designated provider) provide the care. If we decide to
operation, and includes a detailed telephone directory for               have a Plan Hospital, Plan Skilled Nursing Facility, or
appointments and advice. Your Guidebook provides other                   designated Non–Plan Provider provide your care, we
important information, such as preventive care guidelines                may authorize special transportation services that are
and your Member rights and responsibilities. Your                        medically required to get you to the provider. This may
Guidebook is subject to change and is periodically                       include transportation that is otherwise not covered.
updated. You can get a copy by visiting our website at
kp.org or by calling our Member Service Call Center.                     Be sure to ask the Non–Plan Provider to tell you what
                                                                         care (including any transportation) we have authorized
                                                                         because we will not cover unauthorized Post-
                                                                         Stabilization Care or related transportation provided by
Emergency Services and Urgent                                            Non–Plan Providers.
Care
                                                                         We understand that extraordinary circumstances can
                                                                         delay your ability to call us to request authorization for
Emergency Services                                                       Post-Stabilization Care from a Non–Plan Provider, for
                                                                         example, if a young child is without a parent or guardian
If you have an Emergency Medical Condition, call 911
                                                                         present, or you are unconscious. In these cases, you must
(where available) or go to the nearest hospital
                                                                         call us as soon as reasonably possible. Please keep in
Emergency Department. You do not need prior
                                                                         mind that anyone can call us for you. We do not cover
authorization for Emergency Services. When you have
                                                                         any care you receive from Non–Plan Providers after your
an Emergency Medical Condition, we cover Emergency


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 17
Emergency Medical Condition is Stabilized unless we               deterioration of your (or your unborn child's) health from
authorize it, so if you don't call as soon as reasonably          a Non–Plan Provider if all of the following are true:
possible, you increase the risk that you will have to pay         • You receive the Services from Non–Plan Providers
for this care.                                                      while you are temporarily outside our Service Area
Cost Sharing                                                      • You reasonably believed that your (or your unborn
The Cost Sharing for covered Emergency Services and                 child's) health would seriously deteriorate if you
Post-Stabilization Care is the Cost Sharing required for            delayed treatment until you returned to our Service
Services provided by Plan Providers as described in the             Area
"Benefits and Cost Sharing" section:
                                                                  You do not need prior authorization for Out-of-Area
• Please refer to "Outpatient Care" for the Cost Sharing          Urgent Care. We cover Out-of-Area Urgent Care you
  for Emergency Department visits                                 receive from Non–Plan Providers as long as the Services
• The Cost Sharing for other covered Emergency                    would have been covered under the "Benefits and Cost
  Services and Post-Stabilization Care is the Cost                Sharing" section (subject to the "Exclusions, Limitations,
  Sharing that you would pay if the Services were not             Coordination of Benefits, and Reductions" section) if
  Emergency Services or Post-Stabilization Care. For              you had received them from Plan Providers.
  example, if you are admitted as an inpatient to a Non–
  Plan Hospital for Post-Stabilization Care and we give           Cost Sharing
  prior authorization for that care, your Cost Sharing            The Cost Sharing for covered Urgent Care is the Cost
  would be the Cost Sharing listed under "Hospital                Sharing required for Services provided by Plan Providers
  Inpatient Care"                                                 as described in the "Benefits and Cost Sharing" section:
                                                                  • Please refer to "Outpatient Care" for the Cost Sharing
Services not covered under this "Emergency
                                                                    for Urgent Care consultations and exams
Services" section
Coverage for the following Services is described in other         • The Cost Sharing for other covered Urgent Care is the
sections of this Membership Agreement and Evidence of               Cost Sharing that you would pay if the Services were
Coverage:                                                           not Urgent Care. For example, if the Urgent Care you
                                                                    receive includes an X-ray, your Cost Sharing for the
• Follow-up care and other Services that are not                    X-ray would be the Cost Sharing for an X-ray listed
  Emergency Services or Post-Stabilization Care                     under "Outpatient Imaging, Laboratory, and Special
  described in this "Emergency Services" section (refer             Procedures"
  to the "Benefits and Cost Sharing" section for
  coverage, subject to the "Exclusions, Limitations,              Services not covered under this "Urgent Care"
  Coordination of Benefits, and Reductions" section)              section
• Out-of-Area Urgent Care (refer to "Out-of-Area                  Coverage for the following Services is described in other
  Urgent" care under "Urgent Care" in this "Emergency             sections of this Membership Agreement and Evidence of
  Services and Urgent Care" section)                              Coverage:
                                                                  • Follow-up care and other Services that are not Urgent
Urgent Care                                                         Care or Out-of-Area Urgent Care described in this
                                                                    "Urgent Care" section (refer to the "Benefits and Cost
Inside the Service Area                                             Sharing" section for coverage, subject to the
An Urgent Care need is one that requires prompt medical             "Exclusions, Limitations, Coordination of Benefits,
attention but is not an Emergency Medical Condition. If             and Reductions" section)
you think you may need Urgent Care, call the
appropriate appointment or advice telephone number at a
Plan Facility. Please refer to Your Guidebook for                 Payment and Reimbursement
appointment and advice telephone numbers.                         If you receive Emergency Services, Post-Stabilization
                                                                  Care, or Out-of-Area Urgent Care from a Non–Plan
Out-of-Area Urgent Care                                           Provider as described in this "Emergency Services and
If you have an Urgent Care need due to an unforeseen              Urgent Care" section, or emergency ambulance Services
illness, unforeseen injury, or unforeseen complication of         described under "Ambulance Services" in the "Benefits
an existing condition (including pregnancy), we cover             and Cost Sharing" section, you must pay the provider
Medically Necessary Services to prevent serious                   and file a claim for reimbursement unless the provider
                                                                  agrees to bill us. Also, you may be required to pay and


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                          Page 18
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
file a claim for any Services prescribed by a Non–Plan                   • The completed claim form and any bills or receipts
Provider as part of covered Emergency Services, Post-                      must be mailed to the following address as soon as
Stabilization Care, and Out-of-Area Urgent Care even if                    possible after receiving the care:
you receive the Services from a Plan Provider, such as a                    Kaiser Foundation Health Plan, Inc.
Plan Pharmacy.                                                              Claims Department
                                                                            P.O. Box 7004
We will reduce any payment we make to you or the                            Downey, CA 90242-7004
Non–Plan Provider by applicable Cost Sharing. Also, we
will reduce our payment by any amounts paid or payable                   If we ask you to provide information or complete a
(or that in the absence of this plan would have been                     document in connection with your claim, you must send
payable) for the Services under any insurance policy, or                 it to our Claims Department at the address above. For
any other contract or coverage, or any government                        example, we might request that you provide completed
program except Medicaid. If payment under the other                      claim forms, consents for the release of medical records,
insurance or program is not made within a reasonable                     assignments, claims for any other benefits to which you
period of time, we will pay for covered Emergency                        may be entitled, or verification of your travel or itinerary.
Services, Post-Stabilization Care, and Out-of-Area
Urgent Care received from Non–Plan Providers if you:                     We will send you our written decision within 45 business
• Assign all rights to payment to us and agree to                        days after we receive the claim unless we request
  cooperate with us in obtaining payment                                 additional information from you or the Non–Plan
                                                                         Provider. If we request additional information, we will
• Allow us to obtain any relevant information from the
                                                                         send our written decision no later than 45 business days
  other insurance or program
                                                                         after the date we receive the additional information. If
• Provide us with any information and assistance we                      we do not receive the necessary information within the
  need to obtain payment from the other insurance or                     timeframe specified in the letter, we will make our
  program                                                                decision based on the information we have. If our
                                                                         decision is not fully in your favor, we will tell you the
How to file a claim                                                      reasons and how to file a grievance as described under
To file a claim for payment or reimbursement, this is                    "Grievances" in the "Dispute Resolution" section.
what you need to do:
• As soon as possible, send us a completed claim form.
  You can get a claim form by visiting our website at                   Benefits and Cost Sharing
  kp.org or by calling our Member Service Call Center
  toll free at 1-800-464-4000 or 1-800-390-3510 (TTY                     We cover the Services described in this "Benefits and
  users call 1-800-777-1370). One of our                                 Cost Sharing" section, subject to the "Exclusions,
  representatives will be happy to assist you if you need                Limitations, Coordination of Benefits, and Reductions"
  help completing our claim form                                         section, only if all of the following conditions are
• If you have paid for Services, you must include any                    satisfied:
  bills and receipts from the Non–Plan Provider with                     • You are a Member on the date that you receive the
  your claim form                                                          Services
• To request that we pay a Non–Plan Provider for                         • The Services are Medically Necessary
  Services, you must include any bills from the Non–
  Plan Provider with your claim form. If the Non–Plan                    • The Services are one of the following:
  Provider states that they will submit the claim, you                      ♦ health care items and services for preventive care
  are still responsible for making sure that we receive                     ♦ health care items and services for diagnosis,
  everything we need to process the request for                                 assessment, or treatment
  payment. If you later receive any bills from the Non–
                                                                            ♦ health education covered under "Health
  Plan Provider for covered Services (other than bills
                                                                                Education" in this "Benefits and Cost Sharing"
  for your Cost Sharing amount), please call our
                                                                                section
  Member Service Call Center toll free at
  1-800-390-3510 for assistance                                             ♦ other health care items and services




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 19
• The Services are provided, prescribed, authorized, or            Cost Sharing
  directed by a Plan Physician except where
  specifically noted to the contrary in the sections listed        At the time you receive covered Services, you must pay
  below for the following Services:                                the Cost Sharing in effect on that date, except as follows:
   ♦ emergency ambulance Services as described under               • If you are receiving covered inpatient hospital or
       "Ambulance Services" in this "Benefits and Cost               Skilled Nursing Facility Services on the effective date
       Sharing" section                                              of this Membership Agreement and Evidence of
   ♦ Emergency Services, Post-Stabilization Care, and                Coverage, you pay the Cost Sharing in effect on your
       Out-of-Area Urgent Care as described in the                   admission date until you are discharged if the
       "Emergency Services and Urgent Care" section                  Services were covered under your prior Health Plan
                                                                     evidence of coverage and there has been no break in
• You receive the Services from Plan Providers inside                coverage. However, if the Services were not covered
  our Service Area, except where specifically noted to               under your prior Health Plan evidence of coverage, or
  the contrary in the sections listed below for the                  if there has been a break in coverage, you pay the
  following Services:                                                Cost Sharing in effect on the date you receive the
   ♦ authorized referrals as described under "Getting a              Services
       Referral" in the "How to Obtain Services" section
                                                                   • For items ordered in advance, you pay the Cost
   ♦ emergency ambulance Services as described under                 Sharing in effect on the order date (although we will
       "Ambulance Services" in this "Benefits and Cost               not cover the item unless you still have coverage for
       Sharing" section                                              it on the date you receive it) and you may be required
   ♦ Emergency Services, Post-Stabilization Care, and                to pay the Cost Sharing when the item is ordered. For
       Out-of-Area Urgent Care as described in the                   outpatient prescription drugs, the order date is the
       "Emergency Services and Urgent Care" section                  date that the pharmacy processes the order after
   ♦ hospice care as described under "Hospice Care" in               receiving all of the information they need to fill the
       this "Benefits and Cost Sharing" section                      prescription
• The Medical Group has given prior authorization for              • If you receive more than one Service from a provider,
  the Services if required under "Medical Group                      or Services from more than one provider, you may be
  authorization procedure for certain referrals" in the              required to pay separate Cost Sharing amounts for
  "How to Obtain Services" section                                   each Service and each provider. For example, if you
                                                                     receive both preventive Services and non-preventive
The only Services we cover under this Membership                     Services in the same visit, you may have to pay
Agreement and Evidence of Coverage are those that this               separate Cost Sharing for each Service received
"Benefits and Cost Sharing" section says that we cover,              during that visit. Similarly, if your physician requests
subject to exclusions and limitations described in this              the assistance of another Plan Provider during a
"Benefits and Cost Sharing" section and to all provisions            procedure, you may have to pay separate Cost
in the "Exclusions, Limitations, Coordination of                     Sharing amounts for the Services provided by each
Benefits, and Reductions" section. The "Exclusions,                  Plan Provider. If you have questions about Cost
Limitations, Coordination of Benefits, and Reductions"               Sharing, please contact our Member Service Call
section describes exclusions, limitations, reductions, and           Center
coordination of benefits provisions that apply to all              • In some cases, we may agree to bill you for your Cost
Services that would otherwise be covered. When an                    Sharing amounts
exclusion or limitation applies only to a particular
benefit, it is listed in the description of that benefit in this   If you receive Services that are not covered under this
"Benefits and Cost Sharing" section. Also, please refer            Membership Agreement and Evidence of Coverage, you
to:                                                                may be liable for the full price of those Services.
• The "Emergency Services and Urgent Care" section
  for information about how to obtain covered                      Deductibles
  Emergency Services, Post-Stabilization Care, and                 In any calendar year, you must pay Charges for certain
  Out-of-Area Urgent Care                                          Services until you meet the Deductible. The Deductible
• Your Guidebook for the types of covered Services                 is $1,500 per calendar year.
  that are available from each Plan Facility in your
  area, because some facilities provide only specific              After you meet the Deductible and for the remainder of
  types of covered Services                                        the calendar year, you pay the applicable Copayment or
                                                                   Coinsurance subject to the limits described under



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                            Page 20
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
"Annual out-of-pocket maximum" in this "Benefits and                     same calendar year. The limit is $3,500 per calendar
Cost Sharing" section.                                                   year.

Services that are subject to the Deductible. All                         Payments that count toward the maximum. Any
covered Services are subject to the Deductible, except for               amounts you pay for covered Services subject to the
those covered under "Outpatient Prescription Drugs,                      Deductible, as described under "Deductibles," apply
Supplies, and Supplements" in this "Benefits and Cost                    toward the annual out-of-pocket maximum. Also, the
Sharing" section, the "Chiropractic Services                             Copayments and Coinsurance you pay for the following
Amendment," and those that are listed as not subject to                  Services apply toward the annual out-of-pocket
the Deductible in this "Benefits and Cost Sharing"                       maximum:
section.
                                                                         • Administered drugs
When Services are subject to a Deductible and you have                   • Ambulance Services
not met the Deductible, you must pay Charges for the                     • Amino acid–modified products used to treat
Services you are scheduled to receive when you check in                    congenital errors of amino acid metabolism (such as
for an appointment or procedure. Note: When we cover                       phenylketonuria)
Services at "no charge" subject to the Deductible and you
                                                                         • Diabetic testing supplies and equipment and insulin-
have not met your Deductible, you must pay Charges for
the Services.                                                              administration devices
                                                                         • Emergency Department visits
If you would like an estimate of the Charges for a                       • Home health care
Service before you schedule an appointment or
procedure, please go to our website at kp.org or call our                • Hospice care
Member Service Call Center toll free at 1-800-390-3507.                  • Hospital care, except that for mental health hospital
Note: If you pay a Deductible amount for a Service that                    care, the only care that counts is care for these mental
has a visit limit, the Services count toward reaching the                  health conditions:
limit.                                                                     ♦ Serious Emotional Disturbances of a child
                                                                              described under "Mental Health Services" in this
After you receive the Services, we will compare the                           "Benefits and Cost Sharing" section
Charges for the Services subject to the Deductible that
                                                                            ♦ these Severe Mental Illnesses: schizophrenia,
you actually received against what you paid when you
                                                                                schizoaffective disorder, bipolar disorder (manic-
checked in for an appointment or procedure. If you
                                                                                depressive illness), major depressive disorders,
overpaid, we will send you a refund promptly. If you
                                                                                panic disorder, obsessive-compulsive disorder,
underpaid, we will bill you.
                                                                                pervasive developmental disorder or autism,
                                                                                anorexia nervosa, and bulimia nervosa
Keeping track of the Deductible. When you pay an
amount toward your Deductible, we will give you a                        • Imaging, laboratory, and special procedures
receipt and we will send you a statement. The statement                  • Intensive psychiatric treatment programs
will include the total amount you have paid toward your
                                                                         • Outpatient surgery
Deductible. You can also obtain a copy of this statement
from our Member Service Call Center toll free at                         • Prosthetic and orthotic devices
1-800-390-3507. Any overpayments will be refunded to                     • Services performed during an office visit (including
you promptly.                                                              professional Services such as dialysis treatment,
                                                                           health education counseling and programs, and
Copayments and Coinsurance                                                 physical, occupational, and speech therapy).
The Copayment or Coinsurance you must pay for each                         However, chemical dependency and chiropractic
covered Service (after you meet any applicable                             consultations and treatment do not count toward the
Deductible) is described in this "Benefits and Cost                        maximum, and the only mental health Services that
Sharing" section.                                                          count toward the maximum are Services for these
                                                                           mental health conditions:
Annual out-of-pocket maximum
                                                                           ♦ Serious Emotional Disturbances of a child
There is a limit to the total amount of Cost Sharing you                      described under "Mental Health Services" in this
must pay under this Membership Agreement and                                  "Benefits and Cost Sharing" section
Evidence of Coverage in a calendar year for all of the
                                                                            ♦ these Severe Mental Illnesses: schizophrenia,
covered Services listed below that you receive in the
                                                                                schizoaffective disorder, bipolar disorder (manic-


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 21
       depressive illness), major depressive disorders,           • Family planning counseling and programs
       panic disorder, obsessive-compulsive disorder,
                                                                  • Flexible sigmoidoscopies and colonoscopies
       pervasive developmental disorder or autism,
       anorexia nervosa, and bulimia nervosa                      • Health education counseling and programs
• Skilled Nursing Facility care                                   • Hearing exams and screenings
                                                                  • Immunizations (including vaccines) administered in a
Keeping track of the maximum. When you pay Cost                     Plan Medical Office
Sharing that applies toward the annual out-of-pocket
                                                                  • Preventive counseling, such as STD prevention
maximum, we will give you a receipt. We will also send
                                                                    counseling
you a statement summarizing the amounts you have paid
toward your annual out-of-pocket maximum. You can                 • Routine preventive imaging services, including the
also obtain a copy of this statement from our Member                following:
Service Call Center toll free at 1-800-390-3507.                    ♦ abdominal aortic aneurysm screening
                                                                     ♦ bone density scans
Preventive Care Services                                             ♦ mammograms
                                                                     ♦ ultrasounds
We cover a variety of preventive care Services, which
are Services that do one or more of the following:                • Routine physical maintenance exams, including well-
                                                                    woman exams
• Protect against disease, such as in the use of
  immunizations                                                   • Routine preventive retinal photography screenings

• Promote health, such as counseling on tobacco use               • Scheduled prenatal care exams and first postpartum
                                                                    follow-up consultation and exam
• Detect disease in its earliest stages before noticeable
  symptoms develop, such as screening for breast                  • Tuberculosis tests
  cancer                                                          • Well-child preventive care exams (0–23 months)
                                                                  • The following laboratory tests:
This "Preventive Care Services" section explains Cost
Sharing for some preventive care Services, but does not              ♦ routine preventive laboratory tests, such as
otherwise explain coverage. These preventive care                       cervical cancer screenings
Services are subject to all coverage requirements                    ♦ cholesterol tests (lipid panel and profile)
described in other parts of this "Benefits and Cost                  ♦ diabetes screening (fasting blood glucose tests)
Sharing" section and all provisions in the "Exclusions,
                                                                     ♦ fecal occult blood tests
Limitations, Coordination of Benefits, and Reductions"
section. For example, we cover a preventive care Service             ♦ HIV tests
that is an outpatient laboratory Service only if it is               ♦ prostate specific antigen tests
covered as described under the "Outpatient Imaging,                  ♦ certain sexually transmitted disease (STD) tests
Laboratory, and Special Procedures" section, subject to
the "Exclusions, Limitations, Coordination of Benefits,           If you receive both preventive and non-preventive
and Reductions" section.                                          Services in the same visit, you may have to pay separate
                                                                  Cost Sharing amounts for each Service received during
We cover at no charge (not subject to the Deductible)             that visit. For example, if you go in for a preventive
the preventive care Services listed on our "Health                exam, and your physician diagnoses you with an
Reform Preventive Services List - CA regions." This list          infection, you may have to pay separate Cost Sharing
is subject to change at any time and is available from            amounts for both the preventive exam and for the
Member Services or on our website at                              Services performed to diagnose a condition.
kp.org/formsandpubs. If you receive any other covered
Services during a preventive care visit, you will pay the
applicable Cost Sharing for those Services.                       Outpatient Care

The following are examples of preventive Services that            We cover the following outpatient care subject to the
are included in our "Health Reform Preventive Services            Cost Sharing indicated:
List - CA Regions":                                               • Most primary and specialty care consultations and
• Eye exams for refraction and preventive vision                    exams: a $30 Copayment per visit (not subject to
  screenings                                                        the Deductible)



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                             Page 22
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Routine physical maintenance exams, including well-                       above are covered under "Outpatient Imaging,
  woman exams: no charge (not subject to the                                Laboratory, and Special Procedures")
  Deductible)                                                            • Voluntary termination of pregnancy: a
• Well-child preventive exams for Members through                          $30 Copayment per procedure subject to the
  age 23 months: no charge (not subject to the                             Deductible
  Deductible)                                                            • Physical, occupational, and speech therapy: a
• Family planning counseling, or to obtain internally                      $30 Copayment per visit subject to the Deductible
  implanted time-release contraceptives or intrauterine                  • Physical, occupational, and speech therapy provided
  devices (IUDs) prescribed in accord with our drug                        in an organized, multidisciplinary rehabilitation day-
  formulary guidelines: no charge (not subject to the                      treatment program: a $30 Copayment per day
  Deductible)                                                              subject to the Deductible
• After confirmation of pregnancy, the normal series of                  • Urgent Care consultations and exams: a
  regularly scheduled preventive care prenatal care                        $30 Copayment per visit (not subject to the
  exams and the first postpartum follow-up consultation                    Deductible)
  and exam: no charge (not subject to the
  Deductible)                                                            • Emergency Department visits: a $150 Copayment
                                                                           per visit subject to the Deductible. After you meet
• Alcohol and substance abuse interventions:                               the Deductible, the Emergency Department
  no charge (not subject to the Deductible)                                Copayment does not apply if you are admitted
• Developmental screenings to diagnose and assess                          directly to the hospital as an inpatient for covered
  potential developmental delays: no charge (not                           Services, or if you are admitted for observation and
  subject to the Deductible)                                               are then admitted directly to the hospital as an
                                                                           inpatient for covered Services (for inpatient care,
• Immunizations (including vaccines) administered to
                                                                           please refer to "Hospital Inpatient Care" in this
  you in a Plan Medical Office: no charge (not subject
                                                                           "Benefits and Cost Sharing" section). However, after
  to the Deductible)
                                                                           you meet the Deductible, the Emergency Department
• Flexible sigmoidoscopies: no charge (not subject to                      Copayment does apply if you are admitted for
  the Deductible)                                                          observation but are not admitted as an inpatient
• Colonoscopies: no charge (not subject to the                           • House calls by a Plan Physician (or a Plan Provider
  Deductible)                                                              who is a registered nurse) inside our Service Area
• Allergy injections (including allergy serum): a                          when care can best be provided in your home as
  $5 Copayment per visit subject to the Deductible                         determined by a Plan Physician: no charge (not
                                                                           subject to the Deductible)
• Outpatient surgery: a $250 Copayment per
  procedure subject to the Deductible if it is provided                  • Acupuncture Services provided for the treatment of
  in an outpatient or ambulatory surgery center or in a                    nausea or as part of a multidisciplinary pain
  hospital operating room, or if it is provided in any                     management program for the treatment of chronic
  setting and a licensed staff member monitors your                        pain: a $30 Copayment per visit (not subject to the
  vital signs as you regain sensation after receiving                      Deductible)
  drugs to reduce sensation or to minimize discomfort.                   • Blood, blood products, and their administration:
  Any other outpatient surgery is covered at a                             no charge subject to the Deductible
  $30 Copayment per procedure (not subject to the
                                                                         • Administered drugs (drugs, injectables, radioactive
  Deductible)
                                                                           materials used for therapeutic purposes, and allergy
• Outpatient procedures (other than surgery): a                            test and treatment materials) prescribed in accord
  $250 Copayment per procedure subject to the                              with our drug formulary guidelines, if administration
  Deductible if a licensed staff member monitors your                      or observation by medical personnel is required and
  vital signs as you regain sensation after receiving                      they are administered to you in a Plan Medical Office
  drugs to reduce sensation or to minimize discomfort.                     or during home visits: no charge (not subject to the
  All outpatient procedures that do not require a                          Deductible)
  licensed staff member to monitor your vital signs as
                                                                         • Some types of outpatient consultations and exams
  described above are covered at the Cost Sharing
                                                                           may be available as group appointments, which we
  that would otherwise apply for the procedure in
                                                                           cover at a $15 Copayment per visit (not subject to
  this "Benefits and Cost Sharing" section (for example,
                                                                           the Deductible)
  radiology procedures that do not require a licensed
  staff member to monitor your vital signs as described


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 23
Services not covered under this "Outpatient                          Supplements" in this "Benefits and Cost Sharing"
Care" section                                                        section)
The following types of outpatient Services are covered            • Radioactive materials used for therapeutic purposes
only as described under these headings in this "Benefits
and Cost Sharing" section:                                        • Durable medical equipment and medical supplies

• Bariatric Surgery                                               • Imaging, laboratory, and special procedures,
                                                                    including MRI, CT, and PET scans
• Chemical Dependency Services
                                                                  • Blood, blood products, and their administration
• Dental and Orthodontic Services
                                                                  • Obstetrical care and delivery (including cesarean
• Dialysis Care                                                     section). Note: If you are discharged within 48 hours
• Durable Medical Equipment for Home Use                            after delivery (or within 96 hours if delivery is by
                                                                    cesarean section), your Plan Physician may order a
• Health Education
                                                                    follow-up visit for you and your newborn to take
• Hearing Services                                                  place within 48 hours after discharge (for visits after
• Home Health Care                                                  you are released from the hospital, please refer to
                                                                    "Outpatient Care" in this "Benefits and Cost Sharing"
• Hospice Care                                                      section)
• Mental Health Services                                          • Physical, occupational, and speech therapy (including
• Ostomy and Urological Supplies                                    treatment in an organized, multidisciplinary
                                                                    rehabilitation program)
• Outpatient Imaging, Laboratory, and Special
  Procedures                                                      • Respiratory therapy
• Outpatient Prescription Drugs, Supplies, and                    • Medical social services and discharge planning
  Supplements
                                                                  Services not covered under this "Hospital
• Prosthetic and Orthotic Devices
                                                                  Inpatient Care" section
• Reconstructive Surgery                                          The following types of inpatient Services are covered
• Services Associated with Clinical Trials                        only as described under the following headings in this
                                                                  "Benefits and Cost Sharing" section:
• Transplant Services
                                                                  • Bariatric Surgery
• Vision Services
                                                                  • Chemical Dependency Services
                                                                  • Dental and Orthodontic Services
Hospital Inpatient Care
                                                                  • Dialysis Care
We cover the following inpatient Services at a
                                                                  • Hospice Care
$500 Copayment per day subject to the Deductible in
a Plan Hospital, when the Services are generally and              • Mental Health Services
customarily provided by acute care general hospitals              • Prosthetic and Orthotic Devices
inside our Service Area:
                                                                  • Reconstructive Surgery
• Room and board, including a private room
  if Medically Necessary                                          • Services Associated with Clinical Trials

• Specialized care and critical care units                        • Skilled Nursing Facility Care

• General and special nursing care                                • Transplant Services

• Operating and recovery rooms
• Services of Plan Physicians, including consultation             Ambulance Services
  and treatment by specialists                                    Emergency
• Anesthesia                                                      We cover at a $150 Copayment per trip subject to the
• Drugs prescribed in accord with our drug formulary              Deductible Services of a licensed ambulance anywhere
  guidelines (for discharge drugs prescribed when you             in the world without prior authorization (including
  are released from the hospital, please refer to                 transportation through the 911 emergency response
  "Outpatient Prescription Drugs, Supplies, and                   system where available) if one of the following is true:



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 24
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• You reasonably believe that you have an Emergency                      For covered Services related to bariatric surgical
  Medical Condition and you reasonably believe that                      procedures that you receive, you will pay the Cost
  your condition requires the clinical support of                        Sharing you would pay if the Services were not
  ambulance transport services                                           related to a bariatric surgical procedure.
• Your treating physician determines that you must be
  transported to another facility because your                           If you live 50 miles or more from the facility to which
  Emergency Medical Condition is not Stabilized and                      you are referred for a covered bariatric surgery, we will
  the care you need is not available at the treating                     reimburse you for certain travel and lodging expenses if
  facility                                                               you receive prior written authorization from the Medical
                                                                         Group and send us adequate documentation including
                                                                         receipts. We will not, however, reimburse you for any
If you receive emergency ambulance Services that are
                                                                         travel or lodging expenses if you were offered a referral
not ordered by a Plan Provider, you must pay the
                                                                         to a facility that is less than 50 miles from your home.
provider and file a claim for reimbursement unless the
                                                                         We will reimburse authorized and documented travel and
provider agrees to bill us. Please refer to "Payment and
                                                                         lodging expenses as follows:
Reimbursement" in the "Emergency Services and Urgent
Care" section for how to file a claim for reimbursement.                 • Transportation for you to and from the facility up to
                                                                           $130 per round trip for a maximum of three trips (one
Nonemergency                                                               pre-surgical visit, the surgery, and one follow-up
Inside our Service Area, we cover nonemergency                             visit), including any trips for which we provided
ambulance and psychiatric transport van Services at a                      reimbursement under any other evidence of coverage
$150 Copayment per trip subject to the Deductible                        • Transportation for one companion to and from the
if a Plan Physician determines that your condition                         facility up to $130 per round trip for a maximum of
requires the use of Services that only a licensed                          two trips (the surgery and one follow-up visit),
ambulance (or psychiatric transport van) can provide and                   including any trips for which we provided
that the use of other means of transportation would                        reimbursement under any other evidence of coverage
endanger your health. These Services are covered only
                                                                         • One hotel room, double-occupancy, for you and one
when the vehicle transports you to or from covered
                                                                           companion not to exceed $100 per day for the pre-
Services.
                                                                           surgical visit and the follow-up visit, up to two days
                                                                           per trip, including any hotel accommodations for
Ambulance Services exclusion
                                                                           which we provided reimbursement under any other
• Transportation by car, taxi, bus, gurney van,                            evidence of coverage
  wheelchair van, and any other type of transportation
                                                                         • Hotel accommodations for one companion not to
  (other than a licensed ambulance or psychiatric
                                                                           exceed $100 per day for the duration of your surgery
  transport van), even if it is the only way to travel to a
                                                                           stay, up to four days, including any hotel
  Plan Provider
                                                                           accommodations for which we provided
                                                                           reimbursement under any other evidence of coverage
Bariatric Surgery
                                                                         Services not covered under this "Bariatric
We cover hospital inpatient care related to bariatric                    Surgery" section
surgical procedures (including room and board, imaging,                  Coverage for the following Services is described under
laboratory, special procedures, and Plan Physician                       these headings in this "Benefits and Cost Sharing"
Services) when performed to treat obesity by                             section:
modification of the gastrointestinal tract to reduce
                                                                         • Outpatient prescription drugs (refer to "Outpatient
nutrient intake and absorption, if all of the following
                                                                           Prescription Drugs, Supplies, and Supplements")
requirements are met:
• You complete the Medical Group–approved pre-
  surgical educational preparatory program regarding                    Chemical Dependency Services
  lifestyle changes necessary for long term bariatric
                                                                         Inpatient detoxification
  surgery success
                                                                         We cover hospitalization at a $500 Copayment per day
• A Plan Physician who is a specialist in bariatric care                 subject to the Deductible in a Plan Hospital only for
  determines that the surgery is Medically Necessary                     medical management of withdrawal symptoms, including
                                                                         room and board, Plan Physician Services, drugs,




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 25
dependency recovery Services, education, and                      Chemical dependency Services exclusion
counseling.
                                                                  • Services in a specialized facility for alcoholism, drug
                                                                    abuse, or drug addiction except as otherwise
Outpatient chemical dependency care
                                                                    described in this "Chemical Dependency Services"
We cover the following Services for treatment of                    section
chemical dependency:
• Day-treatment programs
                                                                  Dental and Orthodontic Services
• Intensive outpatient programs
• Individual and group chemical dependency                        We do not cover most dental and orthodontic Services,
  counseling                                                      but we do cover some dental and orthodontic Services as
                                                                  described in this "Dental and Orthodontic Services"
• Outpatient chemical dependency consultation and                 section.
  treatment for withdrawal symptoms
                                                                  Dental Services for radiation treatment
You pay the following for these covered Services:
                                                                  We cover dental evaluation, X-rays, fluoride treatment,
• Individual chemical dependency consultations and                and extractions necessary to prepare your jaw for
  treatment: a $30 Copayment per visit (not subject               radiation therapy of cancer in your head or neck at a
  to the Deductible)                                              $30 Copayment per visit (not subject to the
• Group chemical dependency treatments: a                         Deductible) if a Plan Physician provides the Services or
  $5 Copayment per visit (not subject to the                      if the Medical Group authorizes a referral to a dentist (as
  Deductible)                                                     described in "Medical Group authorization procedure for
                                                                  certain referrals" under "Getting a Referral" in the "How
                                                                  to Obtain Services" section).
We cover methadone maintenance treatment at
no charge (not subject to the Deductible) for pregnant
                                                                  Dental anesthesia
Members during pregnancy and for two months after
delivery at a licensed treatment center approved by the           For dental procedures at a Plan Facility, we provide
Medical Group. We do not cover methadone                          general anesthesia and the facility's Services associated
maintenance treatment in any other circumstances.                 with the anesthesia if all of the following are true:
                                                                  • You are under age 7, or you are developmentally
Transitional residential recovery Services                          disabled, or your health is compromised
We cover up to 60 days per calendar year of chemical              • Your clinical status or underlying medical condition
dependency treatment in a nonmedical transitional                   requires that the dental procedure be provided in a
residential recovery setting approved in writing by the             hospital or outpatient surgery center
Medical Group. We cover these Services at a
$100 Copayment per admission subject to the                       • The dental procedure would not ordinarily require
Deductible. We do not cover more than 120 days of                   general anesthesia
covered care in any five-consecutive-calendar-year
period. These settings provide counseling and support             We do not cover any other Services related to the dental
services in a structured environment.                             procedure, such as the dentist's Services.

Services not covered under this "Chemical                         For covered dental anesthesia Services, you will pay the
Dependency Services" section                                      Cost Sharing that you would pay for hospital
Coverage for the following Services is described under            inpatient care or outpatient surgery, depending on
these headings in this "Benefits and Cost Sharing"                the setting, subject to the Deductible.
section:
                                                                  Dental and orthodontic Services for cleft palate
• Outpatient self-administered drugs (refer to
                                                                  We cover dental extractions, dental procedures necessary
  "Outpatient Prescription Drugs, Supplies, and
                                                                  to prepare the mouth for an extraction, and orthodontic
  Supplements")
                                                                  Services, if they meet all of the following requirements:
• Outpatient laboratory (refer to "Outpatient Imaging,
                                                                  • The Services are an integral part of a reconstructive
  Laboratory, and Special Procedures")
                                                                    surgery for cleft palate that we are covering under
                                                                    "Reconstructive Surgery" in this "Benefits and Cost
                                                                    Sharing" section



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 26
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• A Plan Provider provides the Services or the Medical                  Dialysis Care
  Group authorizes a referral to a Non-Plan Provider
  who is a dentist or orthodontist (as described in                      We cover acute and chronic dialysis Services if all of the
  "Medical Group authorization procedure for certain                     following requirements are met:
  referrals" under "Getting a Referral" in the "How to                   • The Services are provided inside our Service Area
  Obtain Services" section)
                                                                         • You satisfy all medical criteria developed by the
You pay the following for these dental and orthodontic                     Medical Group and by the facility providing the
Services for cleft palate:                                                 dialysis

• Consultations and exams: a $30 Copayment per visit                     • A Plan Physician provides a written referral for care
                                                                           at the facility
  (not subject to the Deductible)
• Hospital inpatient care: a $500 Copayment per day                      After you receive appropriate training at a dialysis
  subject to the Deductible                                              facility we designate, we also cover equipment and
• Outpatient surgery: a $250 Copayment per                               medical supplies required for home hemodialysis and
  procedure subject to the Deductible if it is provided                  home peritoneal dialysis inside our Service Area at
  in an outpatient or ambulatory surgery center or in a                  no charge subject to the Deductible. Coverage is
  hospital operating room, or if it is provided in any                   limited to the standard item of equipment or supplies that
  setting and a licensed staff member monitors your                      adequately meets your medical needs. We decide
  vital signs as you regain sensation after receiving                    whether to rent or purchase the equipment and supplies,
  drugs to reduce sensation or to minimize discomfort.                   and we select the vendor. You must return the equipment
  Any other outpatient surgery: a $30 Copayment per                      and any unused supplies to us or pay us the fair market
  procedure (not subject to the Deductible)                              price of the equipment and any unused supply when we
                                                                         are no longer covering them.
• Outpatient procedures (other than surgery): a
  $250 Copayment per procedure subject to the
                                                                         You pay the following for these covered Services related
  Deductible if a licensed staff member monitors your
                                                                         to dialysis:
  vital signs as you regain sensation after receiving
  drugs to reduce sensation or to minimize discomfort.                   • Inpatient dialysis care: a $500 Copayment per day
  All outpatient procedures that do not require a                          subject to the Deductible
  licensed staff member to monitor your vital signs as                   • One routine office consultation or exam per month
  described above are covered at the Cost Sharing                          with the multidisciplinary nephrology team:
  that would otherwise apply for the procedure in                          no charge (not subject to the Deductible)
  this "Benefits and Cost Sharing" section (for example,
  radiology procedures that do not require a licensed                    • All other consultations or exams: a $30 Copayment
  staff member to monitor your vital signs as described                    per visit (not subject to the Deductible)
  above are covered under "Outpatient Imaging,                           • Hemodialysis treatment at a Plan Facility: a
  Laboratory, and Special Procedures")                                     $30 Copayment per visit subject to the Deductible

Services not covered under this "Dental and                              Services not covered under this "Dialysis Care"
Orthodontic Services" section                                            section
Coverage for the following Services is described under                   Coverage for the following Services is described under
these headings in this "Benefits and Cost Sharing"                       these headings in this "Benefits and Cost Sharing"
section:                                                                 section:
• Outpatient imaging, laboratory, and special                            • Durable medical equipment for home use (refer to
  procedures (refer to "Outpatient Imaging, Laboratory,                    "Durable Medical Equipment for Home Use")
  and Special Procedures")
                                                                         • Outpatient laboratory (refer to "Outpatient Imaging,
• Outpatient administered drugs (refer to "Outpatient                      Laboratory, and Special Procedures")
  Care"), except that we cover outpatient administered
                                                                         • Outpatient prescription drugs (refer to "Outpatient
  drugs under "Dental anesthesia" in this "Dental and
                                                                           Prescription Drugs, Supplies, and Supplements")
  Orthodontic Services" section
                                                                         • Outpatient administered drugs (refer to "Outpatient
• Outpatient prescription drugs (refer to "Outpatient
                                                                           Care")
  Prescription Drugs, Supplies, and Supplements")




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 27
Dialysis Care exclusions                                          • Bone stimulator
• Comfort, convenience, or luxury equipment, supplies             • Cervical traction (over door)
  and features                                                    • Phototherapy blankets for treatment of jaundice in
• Nonmedical items, such as generators or accessories               newborns
  to make home dialysis equipment portable for travel
                                                                  Outside the Service Area
                                                                  We do not cover most durable medical equipment for
Durable Medical Equipment for Home                                home use outside our Service Area. However, if you live
Use                                                               outside our Service Area, we cover the following durable
                                                                  medical equipment (subject to the Cost Sharing and all
Inside our Service Area, we cover the durable medical             other coverage requirements that apply to durable
equipment specified in this "Durable Medical Equipment            medical equipment for home use inside our Service
for Home Use" section for use in your home (or another            Area) when the item is dispensed at a Plan Facility:
location used as your home) in accord with our durable
medical equipment formulary guidelines. Durable                   • Standard curved handle cane
medical equipment for home use is an item that is                 • Standard crutches
intended for repeated use, primarily and customarily
                                                                  • For diabetes blood testing, blood glucose monitors
used to serve a medical purpose, generally not useful to a
                                                                    and their supplies (such as blood glucose monitor test
person who is not ill or injured, and appropriate for use
                                                                    strips, lancets, and lancet devices) from a Plan
in the home.
                                                                    Pharmacy
Coverage is limited to the standard item of equipment             • Insulin pumps and supplies to operate the pump (but
that adequately meets your medical needs. Covered                   not including insulin or any other drugs), after
durable medical equipment (including repair or                      completion of training and education on the use of the
replacement of covered equipment, unless due to loss or             pump
misuse) is provided at 30% Coinsurance (not subject               • Nebulizers and their supplies for the treatment of
to the Deductible). We decide whether to rent or                    pediatric asthma
purchase the equipment, and we select the vendor. You
must return the equipment to us or pay us the fair market         • Peak flow meters from a Plan Pharmacy
price of the equipment when we are no longer covering
it.                                                               About our durable medical equipment formulary
                                                                  Our durable medical equipment formulary includes the
Inside our Service Area, we cover the following durable           list of durable medical equipment that has been approved
medical equipment for use in your home (or another                by our Durable Medical Equipment Formulary Executive
location used as your home):                                      Committee for our Members. Our durable medical
                                                                  equipment formulary was developed by a
• For diabetes blood testing, blood glucose monitors              multidisciplinary clinical and operational work group
  and their supplies (such as blood glucose monitor test          with review and input from Plan Physicians and medical
  strips, lancets, and lancet devices)                            professionals with durable medical equipment expertise
• Infusion pumps (such as insulin pumps) and supplies             (for example: physical, respiratory, and enterostomal
  to operate the pump (but not including insulin or any           therapists and home health). A multidisciplinary Durable
  other drugs)                                                    Medical Equipment Formulary Executive Committee is
                                                                  responsible for reviewing and revising the durable
• Standard curved handle or quad cane and replacement
                                                                  medical equipment formulary. Our durable medical
  supplies
                                                                  equipment formulary is periodically updated to keep
• Standard or forearm crutches and replacement                    pace with changes in medical technology and clinical
  supplies                                                        practice.
• Dry pressure pad for a mattress
                                                                  Our formulary guidelines allow you to obtain
• Nebulizer and supplies                                          nonformulary durable medical equipment (equipment not
• Peak flow meters                                                listed on our durable medical equipment formulary for
• IV pole                                                         your condition) if the equipment would otherwise be
                                                                  covered and the Medical Group determines that it is
• Tracheostomy tube and supplies                                  Medically Necessary as described in "Medical Group
• Enteral pump and supplies                                       authorization procedure for certain referrals" under



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                         Page 28
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
"Getting a Referral" in the "How to Obtain Services"                     • Individual counseling and programs when the visit is
section.                                                                   solely for health education: no charge (not subject
                                                                           to the Deductible)
Services not covered under this "Durable
                                                                         • Health education provided during an outpatient
Medical Equipment for Home Use" section
                                                                           consultation or exam covered in another part of this
Coverage for the following Services is described under                     "Benefits and Cost Sharing" section: no additional
these headings in this "Benefits and Cost Sharing"                         Cost Sharing beyond the Cost Sharing required in
section:                                                                   that other part of this "Benefits and Cost
• Dialysis equipment and supplies required for home                        Sharing" section
  hemodialysis and home peritoneal dialysis (refer to                    • Covered health education materials: no charge (not
  "Dialysis Care")                                                         subject to the Deductible)
• Diabetes urine testing supplies and insulin-
  administration devices other than insulin pumps (refer
  to "Outpatient Prescription Drugs, Supplies, and                      Hearing Services
  Supplements")
                                                                         We cover the following:
• Durable medical equipment related to the terminal
                                                                         • Routine preventive hearing screenings: no charge
  illness for Members who are receiving covered
                                                                           (not subject to the Deductible)
  hospice care (refer to "Hospice Care")
                                                                         • Hearing exams to determine the need for hearing
Durable medical equipment for home use                                     correction: no charge (not subject to the
exclusion                                                                  Deductible)
• Comfort, convenience, or luxury equipment or
                                                                         Services not covered under this "Hearing
  features
                                                                         Services" section
                                                                         Coverage for the following Services is described under
Health Education                                                         these headings in this "Benefits and Cost Sharing"
                                                                         section:
We cover a variety of health education counseling,                       • Services related to the ear or hearing other than those
programs, and materials that your personal Plan                            described in this section (refer to the applicable
Physician or other Plan Providers provide during a visit                   heading in this "Benefits and Cost Sharing" section)
covered under another part of this "Benefits and Cost
Sharing" section.                                                        • Cochlear implants and osseointegrated hearing
                                                                           devices (refer to "Prosthetic and Orthotic Devices")
We also cover a variety of health education counseling,
programs, and materials to help you take an active role in               Hearing Services exclusions
protecting and improving your health, including                          • Hearing aids and tests to determine their efficacy, and
programs for tobacco cessation, stress management, and                     hearing tests to determine an appropriate hearing aid
chronic conditions (such as diabetes and asthma). Kaiser
Permanente also offers health education counseling,
programs, and materials that are not covered, and you                   Home Health Care
may be required to pay a fee.
                                                                         "Home health care" means Services provided in the
For more information about our health education                          home by nurses, medical social workers, home health
counseling, programs, and materials, please contact your                 aides, and physical, occupational, and speech therapists.
local Health Education Department or our Member                          We cover home health care at no charge (not subject to
Service Call Center, refer to Your Guidebook, or go to                   the Deductible) only if all of the following are true:
our website at kp.org.                                                   • You are substantially confined to your home (or a
                                                                           friend's or relative's home)
You pay the following for these covered Services:                        • Your condition requires the Services of a nurse,
• Group health education programs: no charge (not                          physical therapist, occupational therapist, or speech
  subject to the Deductible)                                               therapist (home health aide Services are not covered
                                                                           unless you are also getting covered home health care
                                                                           from a nurse, physical therapist, occupational




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 29
   therapist, or speech therapist that only a licensed            • Care in the home if the home is not a safe and
   provider can provide)                                            effective treatment setting
• A Plan Physician determines that it is feasible to
  maintain effective supervision and control of your
                                                                  Hospice Care
  care in your home and that the Services can be safely
  and effectively provided in your home                           Hospice care is a specialized form of interdisciplinary
• The Services are provided inside our Service Area               health care designed to provide palliative care and to
                                                                  alleviate the physical, emotional, and spiritual
We cover only part-time or intermittent home health               discomforts of a Member experiencing the last phases of
care, as follows:                                                 life due to a terminal illness. It also provides support to
                                                                  the primary caregiver and the Member's family. A
• Up to two hours per visit for visits by a nurse,
                                                                  Member who chooses hospice care is choosing to receive
  medical social worker, or physical, occupational, or            palliative care for pain and other symptoms associated
  speech therapist, and up to four hours per visit for            with the terminal illness, but not to receive care to try to
  visits by a home health aide                                    cure the terminal illness. You may change your decision
• Up to three visits per day (counting all home health            to receive hospice care benefits at any time.
  visits)
• Up to 100 visits per calendar year (counting all home           We cover the hospice Services listed below at no charge
  health visits)                                                  (not subject to the Deductible) only if all of the
                                                                  following requirements are met:
Note: If a visit by a nurse, medical social worker, or            • A Plan Physician has diagnosed you with a terminal
physical, occupational, or speech therapist lasts longer            illness and determines that your life expectancy is 12
than two hours, then each additional increment of two               months or less
hours counts as a separate visit. If a visit by a home            • The Services are provided inside our Service Area or
health aide lasts longer than four hours, then each                 inside California but within 15 miles or 30 minutes
additional increment of four hours counts as a separate             from our Service Area (including a friend's or
visit. For example, if a nurse comes to your home for               relative's home even if you live there temporarily)
three hours and then leaves, that counts as two visits.
Also, each person providing Services counts toward                • The Services are provided by a licensed hospice
these visit limits. For example, if a home health aide and          agency that is a Plan Provider
a nurse are both at your home during the same two hours,          • The Services are necessary for the palliation and
that counts as two visits.                                          management of your terminal illness and related
                                                                    conditions
The following types of Services are covered only as
described under these headings in this "Benefits and Cost         If all of the above requirements are met, we cover the
Sharing" section:                                                 following hospice Services, which are available on a 24-
• Dialysis Care                                                   hour basis if necessary for your hospice care:
• Durable Medical Equipment for Home Use                          • Plan Physician Services
• Ostomy and Urological Supplies                                  • Skilled nursing care, including assessment,
                                                                    evaluation, and case management of nursing needs,
• Outpatient Prescription Drugs, Supplies, and
                                                                    treatment for pain and symptom control, provision of
  Supplements                                                       emotional support to you and your family, and
• Prosthetic and Orthotic Devices                                   instruction to caregivers
                                                                  • Physical, occupational, or speech therapy for
Home health care exclusions                                         purposes of symptom control or to enable you to
• Care of a type that an unlicensed family member or                maintain activities of daily living
  other layperson could provide safely and effectively            • Respiratory therapy
  in the home setting after receiving appropriate
  training. This care is excluded even if we would                • Medical social services
  cover the care if it were provided by a qualified               • Home health aide and homemaker services
  medical professional in a hospital or a Skilled
                                                                  • Palliative drugs prescribed for pain control and
  Nursing Facility
                                                                    symptom management of the terminal illness for up
                                                                    to a 100-day supply in accord with our drug


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                            Page 30
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   formulary guidelines. You must obtain these drugs                          following areas: self-care, school functioning,
   from Plan Pharmacies. Certain drugs are limited to a                       family relationships, or ability to function in the
   maximum 30-day supply in any 30-day period (please                         community; and either (1) the child is at risk of
   call our Member Service Call Center for the current                        removal from the home or has already been
   list of these drugs)                                                       removed from the home, or (2) the mental disorder
• Durable medical equipment                                                   and impairments have been present for more than
                                                                              six months or are likely to continue for more than
• Respite care when necessary to relieve your                                 one year without treatment
  caregivers. Respite care is occasional short-term
                                                                            ♦ the child displays psychotic features, or risk of
  inpatient care limited to no more than five
                                                                              suicide or violence due to a mental disorder
  consecutive days at a time
                                                                            ♦ the child meets special education eligibility
• Counseling and bereavement services                                           requirements under Chapter 26.5 (commencing
• Dietary counseling                                                            with Section 7570) of Division 7 of Title 1 of the
                                                                                California Government Code
• The following care during periods of crisis when you
  need continuous care to achieve palliation or
  management of acute medical symptoms:                                  Any outpatient visit limits specified under "Outpatient
                                                                         mental health Services" and inpatient day limits specified
   ♦ nursing care on a continuous basis for as much as                   under "Calendar-year day limit for inpatient psychiatric
       24 hours a day as necessary to maintain you at                    hospitalization and intensive psychiatric treatment
       home                                                              programs" do not apply to Severe Mental Illness of a
   ♦ short-term inpatient care required at a level that                  person of any age and the Serious Emotional Disturbance
       cannot be provided at home                                        of a child. For all other mental health conditions, we
                                                                         cover evaluation and treatment only when a Plan
                                                                         Physician or other Plan Provider who is a license health
Mental Health Services                                                   care professional acting within the scope of his or her
                                                                         license believes the condition will significantly improve
We cover Services specified in this "Mental Health
                                                                         with relatively short-term therapy.
Services" section only when the Services are for the
diagnosis or treatment of Mental Disorders.
                                                                         Outpatient mental health Services
A Mental Disorder is a mental health condition as                        We cover the following Services when provided by Plan
identified in the Diagnostic and Statistical Manual of                   Physicians or other Plan Providers who are licensed
Mental Disorders, Fourth Edition, Text Revision (DSM)                    health care professionals acting within the scope of their
that results in clinically significant distress or impairment            license:
of mental, emotional, or behavioral functioning.                         • Up to a combined visit limit of 10 individual and
                                                                           group visits per Member calendar year that include
Mental Disorders include the Severe Mental Illness of a                    Services for mental health evaluation and treatment as
person of any age and the Serious Emotional Disturbance                    described in this "Outpatient mental health Services"
of a Child:                                                                section. Members who have exhausted the 10-visit
                                                                           limitation and who meet Medical Group criteria may
• "Severe Mental Illness" means the following mental
                                                                           receive up to 30 additional group visits in the same
  disorders: schizophrenia, schizoaffective disorder,
                                                                           calendar year
  bipolar disorder (manic-depressive illness), major
  depressive disorders, panic disorder, obsessive-                       • Psychological testing when necessary to evaluate a
  compulsive disorder, pervasive developmental                             Mental Disorder
  disorder or autism, anorexia nervosa, and bulimia                      • Outpatient Services for the purpose of monitoring
  nervosa.                                                                 drug therapy
• A "Serious Emotional Disturbance" of a child under
  age 18 means mental disorders as identified in the                     You pay the following for these covered Services:
  DSM, other than a primary substance use disorder or                    • Individual mental health evaluation and treatment: a
  developmental disorder, that results in behavior                         $30 Copayment per visit (not subject to the
  inappropriate to the child's age according to expected                   Deductible)
  developmental norms, if the child also meets at least
  one of the following three criteria:                                   • Group mental health treatment: a $15 Copayment
                                                                           per visit (not subject to the Deductible)
  ♦ as a result of the mental disorder the child has
     substantial impairment in at least two of the


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 31
Note: Outpatient intensive psychiatric treatment                  cover in a calendar year that are subject to the limit as
programs are not covered under this "Outpatient mental            follows:
health Services" section (refer to "Intensive psychiatric         • Each day of inpatient psychiatric hospitalization
treatment programs" under "Inpatient psychiatric                    counts as one day
hospitalization and intensive psychiatric treatment
programs" in this "Mental Health Services" section).              • Two days of hospital-based intensive outpatient care
                                                                    (partial hospitalization) count as one day
Inpatient psychiatric hospitalization and                         • Three days of treatment in an intensive outpatient
intensive psychiatric treatment programs                            psychiatric treatment program count as one day
Inpatient psychiatric hospitalization. Subject to the             • Each day of treatment in a crisis residential program
day limit described under "Calendar-year day limit for              counts as one day
inpatient psychiatric hospitalization and intensive               • Two psychiatric observation treatment periods of 23
psychiatric treatment programs" in this "Inpatient                  consecutive hours or less count as one day
psychiatric hospitalization and intensive psychiatric
treatment programs" section, we cover inpatient
                                                                  If you reach the day limit, we will not cover any more
psychiatric hospitalization in a Plan Hospital. Coverage
                                                                  inpatient psychiatric hospitalization or intensive
includes room and board, drugs, and Services of Plan
                                                                  psychiatric treatment program Services in that calendar
Physicians or other Plan Providers who are licensed
                                                                  year if they are subject to the day limit.
health care professionals acting within the scope of their
license. We cover these Services at a $500 Copayment
                                                                  Services not covered under this "Mental Health
per day subject to the Deductible.
                                                                  Services" section
                                                                  Coverage for the following Services is described under
Intensive psychiatric treatment programs. Subject to
                                                                  these headings in this "Benefits and Cost Sharing"
the day limit described under "Calendar-year day limit
                                                                  section:
for inpatient psychiatric hospitalization and intensive
psychiatric treatment programs" in this "Inpatient                • Outpatient drugs, supplies, and supplements (refer to
psychiatric hospitalization and intensive psychiatric               "Outpatient Prescription Drugs, Supplies, and
treatment programs" section, we cover at no charge                  Supplements")
subject to the Deductible the following intensive                 • Outpatient laboratory (refer to "Outpatient Imaging,
psychiatric treatment programs at a Plan Facility:                  Laboratory, and Special Procedures")
• Short-term hospital-based intensive outpatient care
  (partial hospitalization)
                                                                  Ostomy and Urological Supplies
• Short-term multidisciplinary treatment in an intensive
  outpatient psychiatric treatment program                        Inside our Service Area, we cover ostomy and urological
• Short-term treatment in a crisis residential program in         supplies prescribed in accord with our soft goods
  licensed psychiatric treatment facility with 24-hour-a-         formulary guidelines at no charge (not subject to the
  day monitoring by clinical staff for stabilization of an        Deductible). We select the vendor, and coverage is
  acute psychiatric crisis                                        limited to the standard supply that adequately meets your
                                                                  medical needs.
• Psychiatric observation for an acute psychiatric crisis
                                                                  About our soft goods formulary
Calendar-year day limit for inpatient psychiatric
                                                                  Our soft goods formulary includes the list of ostomy and
hospitalization and intensive psychiatric treatment
                                                                  urological supplies that have been approved by our Soft
programs. There is a combined day limit of 10 days per
                                                                  Goods Formulary Executive Committee for our
Member per calendar year for psychiatric care described
                                                                  Members. Our Soft Goods Formulary Executive
under "Inpatient psychiatric hospitalization" and
                                                                  Committee is responsible for reviewing and revising the
"Intensive psychiatric treatment programs" in this
                                                                  soft goods formulary. Our soft goods formulary is
"Inpatient psychiatric hospitalization and intensive
                                                                  periodically updated to keep pace with changes in
psychiatric treatment programs" section, except that the
                                                                  medical technology and clinical practice. To find out
day limit does not apply to psychiatric care for the
                                                                  whether a particular ostomy or urological supply is
treatment of Severe Mental Illnesses and Serious
                                                                  included in our soft goods formulary, please call our
Emotional Disturbance of a child under age 18. The
                                                                  Member Service Call Center.
number of days is determined by adding up the number
of days of inpatient psychiatric hospitalization and
intensive psychiatric treatment program Services we


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                            Page 32
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
Our formulary guidelines allow you to obtain                                  subject to the Deductible) when they are ordered
nonformulary ostomy and urological supplies (those not                        as a preventive screening test (and not to diagnose
listed on our soft goods formulary for your condition)                        or treat an existing illness, injury, or condition that
if they would otherwise be covered and the Medical                            has already been diagnosed or for which you have
Group determines that they are Medically Necessary as                         symptoms)
described in "Medical Group authorization procedure for                     ♦ all other laboratory tests: a $10 Copayment per
certain referrals" under "Getting a Referral" in the "How                     encounter subject to the Deductible
to Obtain Services" section.
                                                                         • Routine preventive retinal photography screenings:
Ostomy and urological supplies exclusion                                   no charge (not subject to the Deductible)
                                                                         • All other diagnostic procedures provided by Plan
• Comfort, convenience, or luxury equipment or
                                                                           Providers who are not physicians (such as EKGs and
  features
                                                                           EEGs): a $10 Copayment per encounter subject to
                                                                           the Deductible except that certain diagnostic
Outpatient Imaging, Laboratory, and                                        procedures are covered at a $250 Copayment per
                                                                           procedure subject to the Deductible if they are
Special Procedures
                                                                           provided in an outpatient or ambulatory surgery
We cover the following Services at the Cost Sharing                        center or in a hospital operating room, or if they are
indicated only when prescribed as part of care covered                     provided in any setting and a licensed staff member
under other headings in this "Benefits and Cost Sharing"                   monitors your vital signs as you regain sensation after
section:                                                                   receiving drugs to reduce sensation or to minimize
                                                                           discomfort
• Most diagnostic and therapeutic imaging, such as X-
  rays, mammograms, and ultrasounds: a                                   • Radiation therapy: no charge subject to the
  $10 Copayment per encounter subject to the                               Deductible
  Deductible except that certain imaging procedures                      • Ultraviolet light treatments: no charge (not subject
  are covered at a $250 Copayment per procedure                            to the Deductible)
  subject to the Deductible if they are provided in an
  outpatient or ambulatory surgery center or in a
  hospital operating room, or if they are provided in                   Outpatient Prescription Drugs, Supplies,
  any setting and a licensed staff member monitors                      and Supplements
  your vital signs as you regain sensation after
  receiving drugs to reduce sensation or to minimize                     We cover outpatient drugs, supplies, and supplements
  discomfort                                                             specified in this "Outpatient Prescription Drugs,
                                                                         Supplies, and Supplements" section when prescribed as
• Preventive imaging, such as preventive
                                                                         follows and obtained through a Plan Pharmacy or our
  mammograms, aortic aneurysm screenings, and bone
                                                                         mail-order service:
  density screenings: no charge (not subject to the
  Deductible)                                                            • Items prescribed by Plan Physicians in accord with
                                                                           our drug formulary guidelines
• MRI, most CT, and PET scans: a $50 Copayment
  per procedure subject to the Deductible                                • Items prescribed by the following Non–Plan
                                                                           Providers unless a Plan Physician determines that the
• Nuclear medicine: a $10 Copayment per encounter
                                                                           item is not Medically Necessary or the drug is for a
  subject to the Deductible
                                                                           sexual dysfunction disorder:
• Laboratory tests (including tests for specific genetic                   ♦ Dentists if the drug is for dental care
  disorders for which genetic counseling is available):
                                                                            ♦ Non–Plan Physicians if the Medical Group
  ♦ laboratory tests to monitor the effectiveness of
                                                                                authorizes a written referral to the Non–Plan
     dialysis: no charge subject to the Deductible
                                                                                Physician (in accord with "Medical Group
   ♦ fecal occult blood tests: no charge (not subject to                        authorization procedure for certain referrals" under
     the Deductible)                                                            "Getting a Referral" in the "How to Obtain
   ♦ preventive laboratory tests and screenings,                                Services" section) and the drug, supply, or
     including cervical cancer screenings, prostate                             supplement is covered as part of that referral
     specific antigen tests, cholesterol tests (lipid panel                 ♦ Non–Plan Physicians if the prescription was
     and profile), diabetes screening (fasting blood                            obtained as part of covered Emergency Services,
     glucose tests), certain sexually transmitted disease                       Post-Stabilization Care, or Out-of-Area Urgent
     (STD) tests, and HIV tests: no charge (not                                 Care described in the "Emergency Services and


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 33
       Urgent Care" section (if you fill the prescription at             $30 Copayment for a 61- to 100-day supply at a
       a Plan Pharmacy, you may have to pay Charges                      Plan Pharmacy
       for the item and file a claim for reimbursement as            ♦ a $10 Copayment for up to a 30-day supply or a
       described under "Payment and Reimbursement" in                    $20 Copayment for a 31- to 100-day supply
       the "Emergency Services and Urgent Care"                          through our mail-order service
       section)
                                                                     ♦ drugs prescribed for the treatment of sexual
                                                                         dysfunction disorders: 50% Coinsurance for up
How to obtain covered items
                                                                         to a 100-day supply at a Plan Pharmacy or through
You must obtain covered drugs, supplies, and                             our mail-order service
supplements from a Plan Pharmacy or through our mail-
order service unless the item is covered Emergency                • Brand-name items and compounded products:
Services, Post-Stabilization Care, or Out-of-Area Urgent             ♦ a $35 Copayment for up to a 30-day supply, a
Care described in the "Emergency Services and Urgent                     $70 Copayment for a 31- to 60-day supply, or a
Care" section.                                                           $105 Copayment for a 61- to 100-day supply at a
                                                                         Plan Pharmacy
Please refer to Your Guidebook for the locations of Plan             ♦ a $35 Copayment for up to a 30-day supply or a
Pharmacies in your area.                                                 $70 Copayment for a 31- to 100-day supply
                                                                         through our mail-order service
Refills. You may be able to order refills from a Plan                ♦ drugs prescribed for the treatment of sexual
Pharmacy, our mail-order service, or through our website                 dysfunction disorders: 50% Coinsurance for up
at kp.org/rxrefill. A Plan Pharmacy or Your Guidebook                    to a 100-day supply at a Plan Pharmacy or through
can give you more information about obtaining refills,                   our mail-order service
including the options available to you for obtaining
refills. For example, a few Plan Pharmacies don't                 • Amino acid–modified products used to treat
dispense refills and not all drugs can be mailed through            congenital errors of amino acid metabolism (such as
our mail-order service. Please check with your local Plan           phenylketonuria) and elemental dietary enteral
Pharmacy if you have a question about whether or not                formula when used as a primary therapy for regional
your prescription can be mailed or obtained from a Plan             enteritis: no charge for up to a 30-day supply
Pharmacy. Items available through our mail-order                  • Emergency contraceptive pills: no charge
service are subject to change at any time without notice.
                                                                  • Hematopoietic agents for dialysis: no charge for up
                                                                    to a 30-day supply
Outpatient drugs, supplies, and supplements
We cover the following outpatient drugs, supplies, and            • Continuity drugs (if this Membership Agreement and
supplements:                                                        Evidence of Coverage is amended to exclude a drug
                                                                    that we have been covering and providing to you
• Drugs for which a prescription is required by law. We             under this Membership Agreement and Evidence of
  also cover certain drugs that do not require a                    Coverage, we will continue to provide the drug if a
  prescription by law if they are listed on our drug                prescription is required by law and a Plan Physician
  formulary. Note: Certain tobacco-cessation drugs are              continues to prescribe the drug for the same condition
  covered only if you participate in a behavioral                   and for a use approved by the federal Food and Drug
  intervention program approved by the Medical Group                Administration): 50% Coinsurance for up to a 30-
• Diaphragms, cervical caps, contraceptive rings,                   day supply in a 30-day period
  contraceptive patches, and oral contraceptives
  (including emergency contraceptive pills)                       Note: If Charges for the drug, supply, or supplement are
• Disposable needles and syringes needed for injecting            less than the Copayment, you will pay the lesser amount.
  covered drugs
                                                                  Certain intravenous drugs, supplies, and
• Inhaler spacers needed to inhale covered drugs                  supplements
                                                                  We cover certain self-administered intravenous drugs,
Cost Sharing for outpatient drugs, supplies, and                  fluids, additives, and nutrients that require specific types
supplements. The Cost Sharing for these items is as               of parenteral-infusion (such as an intravenous or
follows:                                                          intraspinal-infusion) at no charge for up to a 30-day
• Generic items:                                                  supply and the supplies and equipment required for their
   ♦ a $10 Copayment for up to a 30-day supply, a                 administration at no charge. Note: Injectable drugs and
       $20 Copayment for a 31- to 60-day supply, or a             insulin are not covered under this paragraph (instead,



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                             Page 34
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
refer to the "Outpatient drugs, supplies, and                            please call our Member Service Call Center. Note: The
supplements" paragraph).                                                 presence of a drug on our drug formulary does not
                                                                         necessarily mean that your Plan Physician will prescribe
Diabetes urine-testing supplies and insulin-                             it for a particular medical condition.
administration devices
We cover ketone test strips and sugar or acetone test                    Our drug formulary guidelines allow you to obtain
tablets or tapes for diabetes urine testing at no charge for             nonformulary prescription drugs (those not listed on our
up to a 100-day supply.                                                  drug formulary for your condition) if they would
                                                                         otherwise be covered and a Plan Physician determines
We cover the following insulin-administration devices at                 that they are Medically Necessary. If you disagree with
a $10 Copayment for up to a 100-day supply: pen                          your Plan Physician's determination that a nonformulary
delivery devices, disposable needles and syringes, and                   prescription drug is not Medically Necessary, you may
visual aids required to ensure proper dosage (except                     file a grievance as described in the "Dispute Resolution"
eyewear).                                                                section. Also, our formulary guidelines may require you
                                                                         to participate in a behavioral intervention program
Day supply limit                                                         approved by the Medical Group for specific conditions
The prescribing physician or dentist determines how                      and you may be required to pay for the program.
much of a drug, supply, or supplement to prescribe. For
purposes of day supply coverage limits, Plan Physicians                  Services not covered under this "Outpatient
determine the amount of an item that constitutes a                       Prescription Drugs, Supplies, and Supplements"
Medically Necessary 30-, 60-, or 100-day supply for you.                 section
Upon payment of the Cost Sharing specified in this                       Coverage for the following Services is described under
"Outpatient Prescription Drugs, Supplies, and                            these headings in this "Benefits and Cost Sharing"
Supplements" section, you will receive the supply                        section:
prescribed up to the day supply limit also specified in                  • Diabetes blood-testing equipment and their supplies,
this section. The day supply limit is either a 30-day                      and insulin pumps and their supplies (refer to
supply in a 30-day period or a 100-day supply in a 100-                    "Durable Medical Equipment for Home Use")
day period. If you wish to receive more than the covered
day supply limit, then you must pay Charges for any                      • Durable medical equipment used to administer drugs
prescribed quantities that exceed the day supply limit.                    (refer to "Durable Medical Equipment for Home
Note: We cover episodic drugs prescribed for the                           Use")
treatment of sexual dysfunction disorders up to a                        • Outpatient administered drugs (refer to "Outpatient
maximum of 8 doses in any 30-day period or up to 27                        Care")
doses in any 100-day period.                                             • Drugs covered during a covered stay in a Plan
                                                                           Hospital or Skilled Nursing Facility (refer to
The pharmacy may reduce the day supply dispensed at                        "Hospital Inpatient Care" and "Skilled Nursing
the Cost Sharing specified in this "Outpatient                             Facility Care")
Prescription Drugs, Supplies, and Supplements" section
to a 30-day supply in any 30-day period if the pharmacy                  • Drugs prescribed for pain control and symptom
determines that the item is in limited supply in the                       management of the terminal illness for Members who
market or for specific drugs (your Plan Pharmacy can tell                  are receiving covered hospice care (refer to "Hospice
you if a drug you take is one of these drugs).                             Care")

About our drug formulary                                                 Outpatient prescription drugs, supplies, and
                                                                         supplements exclusions
Our drug formulary includes the list of drugs that have
been approved by our Pharmacy and Therapeutics                           • Any requested packaging (such as dose packaging)
Committee for our Members. Our Pharmacy and                                other than the dispensing pharmacy's standard
Therapeutics Committee, which is primarily composed                        packaging
of Plan Physicians, selects drugs for the drug formulary                 • Compounded products unless the drug is listed on our
based on a number of factors, including safety and                         drug formulary or one of the ingredients requires a
effectiveness as determined from a review of medical
                                                                           prescription by law
literature. The Pharmacy and Therapeutics Committee
meets quarterly to consider additions and deletions based                • Drugs prescribed to shorten the duration of the
on new information or drugs that become available. If                      common cold
you would like to request a copy of our drug formulary,



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 35
Prosthetic and Orthotic Devices                                   • Prostheses to replace all or part of an external facial
                                                                    body part that has been removed or impaired as a
We do not cover most prosthetic and orthotic devices,               result of disease, injury, or congenital defect
but we do cover devices as described in this "Prosthetic
and Orthotic Devices" section if all of the following             Services not covered under this "Prosthetic and
requirements are met:                                             Orthotic Devices" section
• The device is in general use, intended for repeated             Coverage for the following Services is described under
  use, and primarily and customarily used for medical             these headings in this "Benefits and Cost Sharing"
  purposes                                                        section:
• The device is the standard device that adequately               • Contact lenses to treat aniridia or aphakia (refer to
  meets your medical needs                                          "Vision Services")
• You receive the device from the provider or vendor
                                                                  Prosthetic and orthotic devices exclusions
  that we select
                                                                  • Multifocal intraocular lenses and intraocular lenses to
Coverage includes fitting and adjustment of these                   correct astigmatism
devices, their repair or replacement (unless due to loss or       • Except as otherwise described above in this
misuse), and Services to determine whether you need a               "Prosthetic and Orthotic Devices" section, nonrigid
prosthetic or orthotic device. If we cover a replacement            supplies, such as elastic stockings and wigs
device, then you pay the Cost Sharing that you would
pay for obtaining that device.                                    • Comfort, convenience, or luxury equipment or
                                                                    features
Internally implanted devices                                      • Shoes or arch supports, even if custom-made, except
We cover prosthetic and orthotic devices, such as                   footwear described above in this "Prosthetic and
pacemakers, intraocular lenses, cochlear implants,                  Orthotic Devices" section for diabetes-related
osseointegrated hearing devices, and hip joints, if they            complications
are implanted during a surgery that we are covering
under another section of this "Benefits and Cost Sharing"
section. We cover these devices at no charge subject to           Reconstructive Surgery
the Deductible.
                                                                  We cover the following reconstructive surgery Services:
External devices                                                  • Reconstructive surgery to correct or repair abnormal
We cover the following external prosthetic and orthotic             structures of the body caused by congenital defects,
devices at no charge (not subject to the Deductible):               developmental abnormalities, trauma, infection,
• Prosthetic devices and installation accessories to                tumors, or disease, if a Plan Physician determines that
  restore a method of speaking following the removal                it is necessary to improve function, or create a normal
  of all or part of the larynx (this coverage does not              appearance, to the extent possible
  include electronic voice-producing machines, which              • Following Medically Necessary removal of all or part
  are not prosthetic devices)                                       of a breast, we cover reconstruction of the breast,
• Prostheses needed after a Medically Necessary                     surgery and reconstruction of the other breast to
  mastectomy, including custom-made prostheses when                 produce a symmetrical appearance, and treatment of
  Medically Necessary and up to three brassieres                    physical complications, including lymphedemas
  required to hold a prosthesis every 12 months
                                                                  You pay the following for covered reconstructive surgery
• Podiatric devices (including footwear) to prevent or
                                                                  Services:
  treat diabetes-related complications when prescribed
  by a Plan Physician or by a Plan Provider who is a              • Consultations and exams: a $30 Copayment per visit
  podiatrist                                                        (not subject to the Deductible)
• Compression burn garments and lymphedema wraps                  • Outpatient surgery: a $250 Copayment per
  and garments                                                      procedure subject to the Deductible if it is provided
                                                                    in an outpatient or ambulatory surgery center or in a
• Enteral formula for Members who require tube
                                                                    hospital operating room, or if it is provided in any
  feeding in accord with Medicare guidelines
                                                                    setting and a licensed staff member monitors your
                                                                    vital signs as you regain sensation after receiving
                                                                    drugs to reduce sensation or to minimize discomfort.



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 36
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   Any other outpatient surgery: a $30 Copayment per                        if they were not provided in connection with a clinical
   procedure (not subject to the Deductible)                                trial
• Hospital inpatient care (including room and                            • The clinical trial has a therapeutic intent, and its end
  board, drugs, and Plan Physician Services): a                            points are not defined exclusively to test toxicity
  $500 Copayment per day subject to the Deductible                       • The clinical trial involves a drug that is exempt under
                                                                           federal regulations from a new drug application, or
Services not covered under this "Reconstructive                            the clinical trial is approved by: one of the National
Surgery" section                                                           Institutes of Health, the federal Food and Drug
Coverage for the following Services is described under                     Administration (in the form of an investigational new
these headings in this "Benefits and Cost Sharing"                         drug application), the U.S. Department of Defense, or
section:                                                                   the U.S. Department of Veterans Affairs
• Dental and orthodontic Services that are an integral
  part of reconstructive surgery for cleft palate (refer to              For covered Services related to a clinical trial, you will
  "Dental and Orthodontic Services")                                     pay the Cost Sharing you would pay if the Services
                                                                         were not related to a clinical trial.
• Outpatient imaging and laboratory (refer to
  "Outpatient Imaging, Laboratory, and Special
                                                                         Services associated with clinical trials
  Procedures")
                                                                         exclusions
• Outpatient prescription drugs (refer to "Outpatient
  Prescription Drugs, Supplies, and Supplements")                        • Services that are provided solely to satisfy data
                                                                           collection and analysis needs and are not used in your
• Outpatient administered drugs (refer to "Outpatient                      clinical management
  Care")
                                                                         • Services that are customarily provided by the research
• Prosthetics and orthotics (refer to "Prosthetic and                      sponsors free of charge to enrollees in the clinical
  Orthotic Devices")                                                       trial

Reconstructive surgery exclusions
• Surgery that, in the judgment of a Plan Physician
                                                                        Skilled Nursing Facility Care
  specializing in reconstructive surgery, offers only a                  Inside our Service Area, we cover at a $50 Copayment
  minimal improvement in appearance                                      per day subject to the Deductible up to 60 days per
• Surgery that is performed to alter or reshape normal                   benefit period (including any days we covered under any
  structures of the body in order to improve appearance                  other evidence of coverage) of skilled inpatient Services
                                                                         in a Plan Skilled Nursing Facility. The skilled inpatient
                                                                         Services must be customarily provided by a Skilled
Services Associated with Clinical Trials                                 Nursing Facility, and above the level of custodial or
                                                                         intermediate care.
We cover Services associated with cancer clinical trials
if all of the following requirements are met:
                                                                         A benefit period begins on the date you are admitted to a
• You are diagnosed with cancer                                          hospital or Skilled Nursing Facility at a skilled level of
• You are accepted into a phase I, II, III, or IV clinical               care. A benefit period ends on the date you have not been
  trial for cancer                                                       an inpatient in a hospital or Skilled Nursing Facility,
                                                                         receiving a skilled level of care, for 60 consecutive days.
• Your treating Plan Physician, or your treating Non–                    A new benefit period can begin only after any existing
  Plan Physician if the Medical Group authorizes a                       benefit period ends. A prior three-day stay in an acute
  written referral to the Non–Plan Physician for                         care hospital is not required.
  treatment of cancer (in accord with "Medical Group
  authorization procedure for certain referrals" under                   We cover the following Services:
  "Getting a Referral" in the "How to Obtain Services"
  section), recommends participation in the clinical trial               • Physician and nursing Services
  after determining that it has a meaningful potential to                • Room and board
  benefit you
                                                                         • Drugs prescribed by a Plan Physician as part of your
• The Services would be covered under this                                 plan of care in the Plan Skilled Nursing Facility in
  Membership Agreement and Evidence of Coverage                            accord with our drug formulary guidelines if they are




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 37
   administered to you in the Plan Skilled Nursing                For covered transplant Services that you receive, you
   Facility by medical personnel                                  will pay the Cost Sharing you would pay if the
• Durable medical equipment in accord with our                    Services were not related to a transplant.
  durable medical equipment formulary if Skilled
  Nursing Facilities ordinarily furnish the equipment             We provide or pay for donation-related Services for
                                                                  actual or potential donors (whether or not they are
• Imaging and laboratory Services that Skilled Nursing            Members) in accord with our guidelines for donor
  Facilities ordinarily provide                                   Services at no charge (not subject to the Deductible).
• Medical social services
                                                                  Services not covered under this "Transplant
• Blood, blood products, and their administration
                                                                  Services" section
• Medical supplies                                                Coverage for the following Services is described under
• Physical, occupational, and speech therapy                      these headings in this "Benefits and Cost Sharing"
                                                                  section:
• Respiratory therapy
                                                                  • Outpatient imaging and laboratory (refer to
Services not covered under this "Skilled Nursing                    "Outpatient Imaging, Laboratory, and Special
Facility Care" section                                              Procedures")
Coverage for the following Services is described under            • Outpatient prescription drugs (refer to "Outpatient
these headings in this "Benefits and Cost Sharing"                  Prescription Drugs, Supplies, and Supplements")
section:
                                                                  • Outpatient administered drugs (refer to "Outpatient
• Outpatient imaging, laboratory, and special                       Care")
  procedures (refer to "Outpatient Imaging, Laboratory,
  and Special Procedures")
                                                                  Vision Services
Transplant Services                                               We cover the following:
                                                                  • Routine preventive vision screenings: no charge (not
We cover transplants of organs, tissue, or bone marrow
                                                                    subject to the Deductible)
if the Medical Group provides a written referral for care
to a transplant facility as described in "Medical Group           • Eye exams for refraction to determine the need for
authorization procedure for certain referrals" under                vision correction and to provide a prescription for
"Getting a Referral" in the "How to Obtain Services"                eyeglass lenses: no charge (not subject to the
section.                                                            Deductible)
                                                                  • Up to two Medically Necessary contact lenses, fitting,
After the referral to a transplant facility, the following          and dispensing per eye every 12 months (including
applies:                                                            lenses we covered under any other evidence of
• If either the Medical Group or the referral facility              coverage) to treat aniridia (missing iris): no charge
  determines that you do not satisfy its respective                 (not subject to the Deductible)
  criteria for a transplant, we will only cover Services          • Up to six Medically Necessary aphakic contact
  you receive before that determination is made                     lenses, fitting, and dispensing per eye per calendar
• Health Plan, Plan Hospitals, the Medical Group, and               year (including lenses we covered under any other
  Plan Physicians are not responsible for finding,                  evidence of coverage) to treat aphakia (absence of the
  furnishing, or ensuring the availability of an organ,             crystalline lens of the eye) for Members through age
  tissue, or bone marrow donor                                      9: no charge (not subject to the Deductible)
• In accord with our guidelines for Services for living
                                                                  Services not covered under this "Vision
  transplant donors, we provide certain donation-related
                                                                  Services" section
  Services for a donor, or an individual identified by
  the Medical Group as a potential donor, whether or              • Services related to the eye or vision other than
  not the donor is a Member. These Services must be                 Services covered under this "Vision Services" section
  directly related to a covered transplant for you, which
  may include certain Services for harvesting the organ,          Vision Services exclusions
  tissue, or bone marrow and for treatment of                     • Industrial frames
  complications. Our guidelines for donor Services are
  available by calling our Member Service Call Center


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                          Page 38
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

• Services for the purpose of correcting refractive                      Chiropractic Services
  defects such as myopia, hyperopia, or astigmatism                      Chiropractic Services and the Services of a chiropractor,
• Eyeglass lenses and frames                                             except as described in the "Chiropractic Services
                                                                         Amendment."
• Contact lenses, including fitting and dispensing
  (except for contact lenses to treat aphakia or aniridia                Cosmetic Services
  as described under this "Vision Services" section)
                                                                         Services that are intended primarily to change or
• Eye exams for the purpose of obtaining or                              maintain your appearance, except that this exclusion
  maintaining contact lenses                                             does not apply to any of the following:
• Low vision devices                                                     • Services covered under "Reconstructive Surgery" in
                                                                           the "Benefits and Cost Sharing" section
                                                                         • The following devices covered under "Prosthetic and
Exclusions, Limitations,                                                   Orthotic Devices" in the "Benefits and Cost Sharing"
                                                                           section: testicular implants implanted as part of a
Coordination of Benefits, and                                              covered reconstructive surgery, breast prostheses
Reductions                                                                 needed after a mastectomy and prostheses to replace
                                                                           all or part of an external facial body part

Exclusions                                                               Custodial care
The items and services listed in this "Exclusions" section               Assistance with activities of daily living (for example:
are excluded from coverage. These exclusions apply to                    walking, getting in and out of bed, bathing, dressing,
all Services that would otherwise be covered under this                  feeding, toileting, and taking medicine).
Membership Agreement and Evidence of Coverage
regardless of whether the services are within the scope of               This exclusion does not apply to assistance with
a provider's license or certificate. Additional exclusions               activities of daily living that is provided as part of
that apply only to a particular benefit are listed in the                covered hospice, Skilled Nursing Facility, or inpatient
description of that benefit in the "Benefits and Cost                    hospital care.
Sharing" section.
                                                                         Dental and orthodontic Services
Acupuncture Services                                                     Dental and orthodontic Services such as X-rays,
Acupuncture Services and the Services of an                              appliances, implants, Services provided by dentists or
acupuncturist except for Services covered under                          orthodontists, dental Services following accidental injury
"Outpatient Care" in the "Benefits and Cost Sharing"                     to teeth, and dental Services resulting from medical
section.                                                                 treatment such as surgery on the jawbone and radiation
                                                                         treatment.
Artificial insemination and conception by
artificial means                                                         This exclusion does not apply to Services covered under
All Services related to artificial insemination and                      "Dental and Orthodontic Services" in the "Benefits and
conception by artificial means, such as: ovum                            Cost Sharing" section.
transplants, gamete intrafallopian transfer (GIFT), semen
and eggs (and Services related to their procurement and                  Disposable supplies
storage), in vitro fertilization (IVF), and zygote                       Disposable supplies for home use, such as bandages,
intrafallopian transfer (ZIFT).                                          gauze, tape, antiseptics, dressings, Ace-type bandages,
                                                                         and diapers, underpads, and other incontinence supplies.
Certain exams and Services
Physical exams and other Services (1) required for                       This exclusion does not apply to disposable supplies
obtaining or maintaining employment or participation in                  covered under "Durable Medical Equipment for Home
employee programs, (2) required for insurance or                         Use," "Home Health Care," "Hospice Care," "Ostomy
licensing, or (3) on court order or required for parole or               and Urological Supplies," and "Outpatient Prescription
probation. This exclusion does not apply if a Plan                       Drugs, Supplies, and Supplements" in the "Benefits and
Physician determines that the Services are Medically                     Cost Sharing" section.
Necessary.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 39
Experimental or investigational Services                          • Teaching and support services to develop planning
A Service is experimental or investigational if we, in              skills such as daily activity planning and project or
consultation with the Medical Group, determine that one             task planning
of the following is true:                                         • Items and services that increase academic knowledge
• Generally accepted medical standards do not                       or skills
  recognize it as safe and effective for treating the             • Teaching and support services to increase intelligence
  condition in question (even if it has been authorized
  by law for use in testing or other studies on human             • Academic coaching or tutoring for skills such as
  patients)                                                         grammar, math, and time management

• It requires government approval that has not been               • Teaching you how to read, whether or not you have
  obtained when the Service is to be provided                       dyslexia
                                                                  • Educational testing
This exclusion does not apply to any of the following:            • Teaching art, dance, horse riding, music, play or
• Experimental or investigational Services when an                  swimming
  investigational application has been filed with the             • Teaching skills for employment or vocational
  federal Food and Drug Administration (FDA) and the                purposes
  manufacturer or other source makes the Services
  available to you or Kaiser Permanente through an                • Vocational training or teaching vocational skills
  FDA-authorized procedure, except that we do not                 • Professional growth courses
  cover Services that are customarily provided by
                                                                  • Training for a specific job or employment counseling
  research sponsors free of charge to enrollees in a
  clinical trial or other investigational treatment               • Aquatic therapy and other water therapy
  protocol
                                                                  Massage therapy
• Services covered under "Services Associated with
  Clinical Trials" in the "Benefits and Cost Sharing"
  section                                                         Oral nutrition
                                                                  Outpatient oral nutrition, such as dietary supplements,
Please refer to the "Dispute Resolution" section for              herbal supplements, weight loss aids, formulas, and food.
information about Independent Medical Review related
to denied requests for experimental or investigational            This exclusion does not apply to any of the following:
Services.                                                         • Amino acid–modified products and elemental dietary
                                                                    enteral formula covered under "Outpatient
Hair loss or growth treatment                                       Prescription Drugs, Supplies, and Supplements" in
Items and services for the promotion, prevention, or                the "Benefits and Cost Sharing" section
other treatment of hair loss or hair growth.                      • Enteral formula covered under "Prosthetic and
                                                                    Orthotic Devices" in the "Benefits and Cost Sharing"
Infertility Services
                                                                    section
Services related to the diagnosis and treatment of
infertility.                                                      Residential care
                                                                  Care in a facility where you stay overnight, except that
Intermediate care                                                 this exclusion does not apply when the overnight stay is
Care in a licensed intermediate care facility. This               part of covered care in a hospital, a Skilled Nursing
exclusion does not apply to Services covered under                Facility, inpatient respite care covered in the "Hospice
"Durable Medical Equipment," "Home Health Care," and              Care" section, a licensed facility providing crisis
"Hospice Care" in the "Benefits and Cost Sharing"                 residential Services covered under "Inpatient psychiatric
section.                                                          hospitalization and intensive psychiatric treatment
                                                                  programs" in the "Mental Health Services" section, or a
Items and services that are not health care items                 licensed facility providing transitional residential
and services                                                      recovery Services covered under the "Chemical
For example, we do not cover:                                     Dependency Services" section.
• Teaching manners and etiquette




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                          Page 40
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Routine foot care items and services                                     Surrogacy
Routine foot care items and services that are not                        Services for anyone in connection with a surrogacy
Medically Necessary.                                                     arrangement, except for otherwise-covered Services
                                                                         provided to a Member who is a surrogate. A surrogacy
Services not approved by the federal Food and                            arrangement is one in which a woman (the surrogate)
Drug Administration                                                      agrees to become pregnant and to surrender the baby to
Drugs, supplements, tests, vaccines, devices, radioactive                another person or persons who intend to raise the child.
materials, and any other Services that by law require                    Please refer to "Surrogacy arrangements" under
federal Food and Drug Administration (FDA) approval                      "Reductions" in this "Exclusions, Limitations,
in order to be sold in the U.S. but are not approved by the              Coordination of Benefits, and Reductions" section for
FDA. This exclusion applies to Services provided                         information about your obligations to us in connection
anywhere, even outside the U.S.                                          with a surrogacy arrangement, including your obligation
                                                                         to reimburse us for any Services we cover.
This exclusion does not apply to any of the following:
                                                                         Transgender surgery
• Services covered under the "Emergency Services and
  Urgent Care" section that you receive outside the U.S.
                                                                         Travel and lodging expenses
• Experimental or investigational Services when an                       Travel and lodging expenses, except that in some
  investigational application has been filed with the                    situations if the Medical Group refers you to a Non–Plan
  FDA and the manufacturer or other source makes the                     Provider as described in "Medical Group authorization
  Services available to you or Kaiser Permanente                         procedure for certain referrals" under "Getting a
  through an FDA-authorized procedure, except that we                    Referral" in the "How to Obtain Services" section, we
  do not cover Services that are customarily provided                    may pay certain expenses that we preauthorize in accord
  by research sponsors free of charge to enrollees in a                  with our travel and lodging guidelines not subject to the
  clinical trial or other investigational treatment                      Deductible. Our travel and lodging guidelines are
  protocol                                                               available from our Member Service Call Center.
• Services covered under "Services Associated with
  Clinical Trials" in the "Benefits and Cost Sharing"                    This exclusion does not apply to reimbursement for
  section                                                                travel and lodging expenses provided under "Bariatric
                                                                         Surgery" in the "Benefits and Cost Sharing" section.
Please refer to the "Dispute Resolution" section for
information about Independent Medical Review related
to denied requests for experimental or investigational                  Limitations
Services.                                                                We will make a good faith effort to provide or arrange
                                                                         for covered Services within the remaining availability of
Services performed by unlicensed people
                                                                         facilities or personnel in the event of unusual
Services that are performed safely and effectively by                    circumstances that delay or render impractical the
people who do not require licenses or certificates by the                provision of Services under this Membership Agreement
state to provide health care services and where the                      and Evidence of Coverage, such as major disaster,
Member's condition does not require that the services be                 epidemic, war, riot, civil insurrection, disability of a
provided by a licensed health care provider.                             large share of personnel at a Plan Facility, complete or
                                                                         partial destruction of facilities, and labor disputes. Under
Services related to a noncovered Service                                 these circumstances, if you have an Emergency Medical
When a Service is not covered, all Services related to the               Condition, call 911 or go to the nearest hospital as
noncovered Service are excluded, except for Services we                  described under "Emergency Services" in the
would otherwise cover to treat complications of the                      "Emergency Services and Urgent Care" section, and we
noncovered Service. For example, if you have a                           will provide coverage and reimbursement as described in
noncovered cosmetic surgery, we would not cover                          that section.
Services you receive in preparation for the surgery or for
follow-up care. If you later suffer a life-threatening                   Additional limitations that apply only to a particular
complication such as a serious infection, this exclusion                 benefit are listed in the description of that benefit in the
would not apply and we would cover any Services that                     "Benefits and Cost Sharing" section.
we would otherwise cover to treat that complication.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 41
Coordination of Benefits                                          third party. The proceeds of any judgment or settlement
                                                                  that you or we obtain shall first be applied to satisfy our
If you have Medicare coverage, we will coordinate                 lien, regardless of whether the total amount of the
benefits with your Medicare coverage under Medicare               proceeds is less than the actual losses and damages you
rules. Medicare rules determine which coverage pays               incurred.
first, or is "primary," and which coverage pays second, or
is "secondary." You must give us any information we               Within 30 days after submitting or filing a claim or legal
request to help us coordinate benefits. Please call our           action against a third party, you must send written notice
Member Service Call Center to find out which Medicare             of the claim or legal action to:
rules apply to your situation, and how payment will be                 Southern California Third Party Liability Supervisor
handled.                                                               Kaiser Foundation Health Plan, Inc.
                                                                       Special Recovery Unit
                                                                       Parsons East, Second Floor
Reductions                                                             393 E. Walnut St.
Employer responsibility                                                Pasadena, CA 91188
For any Services that the law requires an employer to
provide, we will not pay the employer, and when we                In order for us to determine the existence of any rights
cover any such Services we may recover the value of the           we may have and to satisfy those rights, you must
Services from the employer.                                       complete and send us all consents, releases,
                                                                  authorizations, assignments, and other documents,
Government agency responsibility                                  including lien forms directing your attorney, the third
                                                                  party, and the third party's liability insurer to pay us
For any Services that the law requires be provided only
                                                                  directly. You may not agree to waive, release, or reduce
by or received only from a government agency, we will
                                                                  our rights under this provision without our prior, written
not pay the government agency, and when we cover any
                                                                  consent.
such Services we may recover the value of the Services
from the government agency.
                                                                  If your estate, parent, guardian, or conservator asserts a
                                                                  claim against a third party based on your injury or
Injuries or illnesses alleged to be caused by
                                                                  illness, your estate, parent, guardian, or conservator and
third parties
                                                                  any settlement or judgment recovered by the estate,
If you obtain a judgment or settlement from or on behalf          parent, guardian, or conservator shall be subject to our
of a third party who allegedly caused an injury or illness        liens and other rights to the same extent as if you had
for which you received covered Services, you must pay             asserted the claim against the third party. We may assign
us Charges for those Services, except that the amount             our rights to enforce our liens and other rights.
you must pay will not exceed the maximum amount
allowed under California Civil Code Section 3040. Note:
                                                                  If you have Medicare, Medicare law may apply with
This "Injuries or illnesses alleged to be caused by third
                                                                  respect to Services covered by Medicare.
parties" section does not affect your obligation to pay
Cost Sharing for these Services, but we will credit any
                                                                  Some providers have contracted with Kaiser Permanente
such payments toward the amount you must pay us under
                                                                  to provide certain Services to Members at rates that are
this paragraph.
                                                                  typically less than the fees that the providers ordinarily
                                                                  charge to the general public ("General Fees"). However,
To the extent permitted or required by law, we have the
                                                                  these contracts may allow the providers to recover all or
option of becoming subrogated to all claims, causes of
                                                                  a portion of the difference between the fees paid by
action, and other rights you may have against a third
                                                                  Kaiser Permanente and their General Fees by means of a
party or an insurer, government program, or other source
                                                                  lien claim under California Civil Code Sections 3045.1–
of coverage for monetary damages, compensation, or
                                                                  3045.6 against a judgment or settlement that you receive
indemnification on account of the injury or illness
                                                                  from or on behalf of a third party. For Services the
allegedly caused by the third party. We will be so
                                                                  provider furnished, our recovery and the provider's
subrogated as of the time we mail or deliver a written
                                                                  recovery together will not exceed the provider's General
notice of our exercise of this option to you or your
                                                                  Fees.
attorney, but we will be subrogated only to the extent of
the total of Charges for the relevant Services.

To secure our rights, we will have a lien on the proceeds
of any judgment or settlement you or we obtain against a


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                            Page 42
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Medicare benefits                                                        arrangement, your estate, parent, guardian, or
Your benefits are reduced by any benefits you have                       conservator and any settlement or judgment recovered by
under Medicare except for Members whose Medicare                         the estate, parent, guardian, or conservator shall be
benefits are secondary by law.                                           subject to our liens and other rights to the same extent as
                                                                         if you had asserted the claim against the third party. We
Surrogacy arrangements                                                   may assign our rights to enforce our liens and other
If you enter into a surrogacy arrangement, you must pay                  rights.
us Charges for covered Services you receive related to
conception, pregnancy, or delivery in connection with                    U.S. Department of Veterans Affairs
that arrangement ("Surrogacy Health Services"), except                   For any Services for conditions arising from military
that the amount you must pay will not exceed the                         service that the law requires the Department of Veterans
compensation you are entitled to receive under the                       Affairs to provide, we will not pay the Department of
surrogacy arrangement. A surrogacy arrangement is one                    Veterans Affairs, and when we cover any such Services
in which a woman agrees to become pregnant and to                        we may recover the value of the Services from the
surrender the baby to another person or persons who                      Department of Veterans Affairs.
intend to raise the child. Note: This "Surrogacy
arrangements" section does not affect your obligation to                 Workers' compensation or employer's liability
pay Cost Sharing for these Services, but we will credit                  benefits
any such payments toward the amount you must pay us                      You may be eligible for payments or other benefits,
under this paragraph.                                                    including amounts received as a settlement (collectively
                                                                         referred to as "Financial Benefit"), under workers'
By accepting Surrogacy Health Services, you                              compensation or employer's liability law. We will
automatically assign to us your right to receive payments                provide covered Services even if it is unclear whether
that are payable to you or your chosen payee under the                   you are entitled to a Financial Benefit, but we may
surrogacy arrangement, regardless of whether those                       recover the value of any covered Services from the
payments are characterized as being for medical                          following sources:
expenses. To secure our rights, we will also have a lien                 • From any source providing a Financial Benefit or
on those payments. Those payments shall first be applied                   from whom a Financial Benefit is due
to satisfy our lien. The assignment and our lien will not
exceed the total amount of your obligation to us under                   • From you, to the extent that a Financial Benefit is
the preceding paragraph.                                                   provided or payable or would have been required to
                                                                           be provided or payable if you had diligently sought to
Within 30 days after entering into a surrogacy                             establish your rights to the Financial Benefit under
arrangement, you must send written notice of the                           any workers' compensation or employer's liability law
arrangement, including the names and addresses of the
other parties to the arrangement, and a copy of any
contracts or other documents explaining the arrangement,                Dispute Resolution
to:
     Surrogacy Third Party Liability Supervisor
     Kaiser Foundation Health Plan, Inc.                                Grievances
     Special Recovery Unit
     Parsons East, Second Floor                                          We are committed to providing you with quality care and
     393 E. Walnut St.                                                   with a timely response to your concerns. You can discuss
     Pasadena, CA 91188                                                  your concerns with our Member Services representatives
                                                                         at most Plan Facilities, or you can call our Member
You must complete and send us all consents, releases,                    Service Call Center.
authorizations, lien forms, and other documents that are
reasonably necessary for us to determine the existence of                You can file a grievance for any issue. Here are some
any rights we may have under this "Surrogacy                             examples of reasons you might file a grievance:
arrangements" section and to satisfy those rights. You                   • You are not satisfied with the quality of care you
may not agree to waive, release, or reduce our rights                      received
under this provision without our prior, written consent.
                                                                         • You received a written denial of Services that require
If your estate, parent, guardian, or conservator asserts a                 prior authorization from the Medical Group or a
claim against a third party based on the surrogacy                         "Notice of Non-Coverage" and you want us to cover
                                                                           the Services


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 43
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
grievance, we will send you a written decision that tells                • You may file for your principal if you are an agent
you the reasons and about additional dispute resolution                    under a currently effective health care proxy, to the
options.                                                                   extent provided under state law
                                                                         • Your physician may request an expedited grievance
Note: If you have an issue that involves an imminent and                   as described under "Expedited grievance" in this
serious threat to your health (such as severe pain or                      "Dispute Resolution" section
potential loss of life, limb, or major bodily function), you
can contact the California Department of Managed
Health Care directly at any time at 1-888-HMO-2219                      Department of Managed Health Care
(TDD 1-877-688-9891) without first filing a grievance                   Complaints
with us.
                                                                         The California Department of Managed Health Care
                                                                         is responsible for regulating health care service
Supporting Documents                                                     plans. If you have a grievance against your health
                                                                         plan, you should first telephone your health plan toll
It is helpful for you to include any information that
clarifies or supports your position. You may want to                     free at 1-800-464-4000 (TTY users call
included supporting information with your grievance,                     1-800-777-1370) and use your health plan's grievance
such as medical records or physician opinions. When                      process before contacting the department. Utilizing this
appropriate, we will request medical records from Plan                   grievance procedure does not prohibit any potential legal
Providers on your behalf. If you have consulted with a                   rights or remedies that may be available to you. If you
Non–Plan Provider and are unable to provide copies of                    need help with a grievance involving an emergency, a
relevant medical records, we will contact the provider to                grievance that has not been satisfactorily resolved by
request a copy of your medical records. We will ask you                  your health plan, or a grievance that has remained
to send or fax us a written authorization so that we can                 unresolved for more than 30 days, you may call the
request your records. If we do not receive the                           department for assistance. You may also be eligible for
information we request in a timely fashion, we will make                 an Independent Medical Review (IMR). If you are
a decision based on the information we have.                             eligible for IMR, the IMR process will provide an
                                                                         impartial review of medical decisions made by a health
                                                                         plan related to the medical necessity of a proposed
Who May File                                                             service or treatment, coverage decisions for treatments
                                                                         that are experimental or investigational in nature and
The following persons may file a grievance:                              payment disputes for emergency or urgent medical
• You may file for yourself                                              services. The department also has a toll-free telephone
• You may appoint someone as your authorized                             number (1-888-HMO-2219) and a TDD line
  representative by completing our authorization form.                   (1-877-688-9891) for the hearing and speech
  Authorization forms are available from your local                      impaired. The department's Internet website
  Member Services Department at a Plan Facility or by                    http://www.hmohelp.ca.gov has complaint forms,
  calling our Member Service Call Center. Your                           IMR application forms and instructions online.
  completed authorization form must accompany the
  grievance
• You may file for your Dependent under age 18,                         Independent Medical Review (IMR)
  except that he or she must appoint you as his or her                   If you qualify, you or your authorized representative may
  authorized representative if he or she has the legal                   have your issue reviewed through the Independent
  right to control release of information that is relevant               Medical Review (IMR) process managed by the
  to the grievance                                                       California Department of Managed Health Care. The
• You may file for your ward if you are a court-                         Department of Managed Health Care determines which
  appointed guardian, except that he or she must                         cases qualify for IMR. This review is at no cost to you.
  appoint you as his or her authorized representative if                 If you decide not to request an IMR, you may give up the
  he or she has the legal right to control release of                    right to pursue some legal actions against us.
  information that is relevant to the grievance
• You may file for your conservatee if you are a court-
  appointed conservator




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 45
• A Plan Physician has said that Services are not                    ♦ by calling our Member Service Call Center at
  Medically Necessary and you want us to cover the                      1-800-464-4000 (TTY users call 1-800-777-1370)
  Services                                                           ♦ through our website at kp.org
• You were told that Services are not covered and you
  believe that the Services should be covered                     We will send you a confirmation letter within five days
                                                                  after we receive your grievance. We will send you our
• You received care from a Non–Plan Provider that we
                                                                  written decision within 30 days after we receive your
  did not authorize (other than Emergency Services,
                                                                  grievance. If we do not approve your request, we will tell
  Post-Stabilization Care, Out-of-Area Urgent Care, or
                                                                  you the reasons and about additional dispute resolution
  emergency ambulance Services) and you want us to
                                                                  options. Note: If we resolve your issue to your
  pay for the care
                                                                  satisfaction by the end of the next business day after we
• We did not decide fully in your favor on a claim for            receive your grievance orally, by fax, or through our
  Services described in the "Emergency Services and               website, and a Member Services representative notifies
  Urgent Care" section or under "Ambulance Services"              you orally about our decision, we will not send you a
  in the "Benefits and Cost Sharing" section and you              confirmation letter or a written decision unless your
  want to appeal our decision                                     grievance involves a coverage dispute, a dispute about
• You are dissatisfied with how long it took to get               whether a Service is Medically Necessary, or an
  Services, including getting an appointment, in the              experimental or investigational treatment.
  waiting room, or in the exam room
                                                                  Expedited grievance
• You want to report unsatisfactory behavior by
                                                                  You or your physician may make an oral or written
  providers or staff, or dissatisfaction with the
                                                                  request that we expedite our decision about your
  condition of a facility
                                                                  grievance if it involves an imminent and serious threat to
• Your membership was terminated retroactively for a              your health, such as severe pain or potential loss of life,
  reason other than nonpayment of Premiums or                     limb, or major bodily function. We will inform you of
  contributions toward the cost of coverage                       our decision within 72 hours (orally or in writing).
• We denied your membership application
                                                                  If the request is for a continuation of an expiring course
Your grievance must explain your issue, such as the               of treatment and you make the request at least 24 hours
reasons why you believe a decision was in error or why            before the treatment expires, we will inform you of our
you are dissatisfied about Services you received. You             decision within 24 hours.
must submit your grievance orally or in writing within
180 days of the date of the incident that caused your             You or your physician must request an expedited
dissatisfaction as follows:                                       decision in one of the following ways and you must
                                                                  specifically state that you want an expedited decision:
• If we did not decide fully in your favor on a claim for
  Services described in the "Emergency Services and               • Call our Expedited Review Unit toll free at
  Urgent Care" section or under "Ambulance Services"                1-888-987-7247 (TTY users call 1-800-777-1370),
  in the "Benefits and Cost Sharing" section and you                which is available Monday through Saturday from
  want to appeal our decision, you can submit your                  8:30 a.m. to 5 p.m. After hours, you may leave a
  grievance in one of the following ways:                           message and a representative will return your call the
                                                                    next business day
  ♦ to the Claims Department at the following address:
        Kaiser Foundation Health Plan, Inc.                       • Send your written request to:
        Special Services Unit                                        Kaiser Foundation Health Plan, Inc.
        P.O. Box 7136                                                Expedited Review Unit
        Pasadena, CA 91109                                           P.O. Box 23170
                                                                     Oakland, CA 94623-0170
   ♦ by calling our Member Service Call Center at
       1-800-464-4000 or 1-800-390-3510 (TTY users                • Fax your written request to our Expedited Review
       call 1-800-777-1370)                                         Unit toll free at 1-888-987-2252
• For all other issues, you can submit your grievance in          • Deliver your request in person to your local Member
  one of the following ways:                                        Services Department at a Plan Facility
   ♦ to the Member Services Department at a Plan
       Facility (please refer to Your Guidebook for               If we do not approve your request for an expedited
       addresses)                                                 decision, we will notify you and we will respond to your
                                                                  grievance within 30 days. If we do not approve your


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                            Page 44
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
   Kaiser Foundation Health Plan, Inc. (Health Plan),                    • Any individual or organization whose contract with
   including any claim for medical or hospital                             any of the organizations identified above requires
   malpractice (a claim that medical services were                         arbitration of claims brought by one or more Member
   unnecessary or unauthorized or were improperly,                         Parties
   negligently, or incompetently rendered), for premises
                                                                         • Any employee or agent of any of the foregoing
   liability, or relating to the coverage for, or delivery
   of, Services, irrespective of the legal theories upon
                                                                         "Claimant" refers to a Member Party or a Kaiser
   which the claim is asserted
                                                                         Permanente Party who asserts a claim as described
• The claim is asserted by one or more Member Parties                    above. "Respondent" refers to a Member Party or a
  against one or more Kaiser Permanente Parties or by                    Kaiser Permanente Party against whom a claim is
  one or more Kaiser Permanente Parties against one or                   asserted.
  more Member Parties
• The claim is not within the jurisdiction of the Small                  Initiating arbitration
  Claims Court                                                           Claimants shall initiate arbitration by serving a Demand
                                                                         for Arbitration. The Demand for Arbitration shall include
• If coverage under this Membership Agreement and
                                                                         the basis of the claim against the Respondents; the
  Evidence of Coverage is subject to the Employee
                                                                         amount of damages the Claimants seek in the arbitration;
  Retirement Income Security Act (ERISA) claims
                                                                         the names, addresses, and telephone numbers of the
  procedure regulation (29 CFR 2560.503-1), the claim
                                                                         Claimants and their attorney, if any; and the names of all
  is not about an "adverse benefit determination" as
                                                                         Respondents. Claimants shall include all claims against
  defined in that regulation. Note: Claims about
                                                                         Respondents that are based on the same incident,
  "adverse benefit determinations" are excluded from
                                                                         transaction, or related circumstances in the Demand for
  this binding arbitration requirement only until such
                                                                         Arbitration.
  time as the regulation prohibiting mandatory binding
  arbitration of this category of claim (29 CFR
                                                                         Serving Demand for Arbitration
  2560.503-1(c)(4)) is modified, amended, repealed,
  superseded, or otherwise found to be invalid. If this                  Health Plan, Kaiser Foundation Hospitals, KP Cal, LLC,
  occurs, these claims will automatically become                         The Permanente Medical Group, Inc., Southern
  subject to mandatory binding arbitration without                       California Permanente Medical Group, The Permanente
  further notice                                                         Federation, LLC, and The Permanente Company, LLC,
                                                                         shall be served with a Demand for Arbitration by mailing
As referred to in this "Binding Arbitration" section,                    the Demand for Arbitration addressed to that Respondent
"Member Parties" include:                                                in care of:
                                                                              Kaiser Foundation Health Plan, Inc.
• A Member                                                                    Legal Department
• A Member's heir, relative, or personal representative                       393 E. Walnut St.
• Any person claiming that a duty to him or her arises                        Pasadena, CA 91188
  from a Member's relationship to one or more Kaiser
  Permanente Parties                                                     Service on that Respondent shall be deemed completed
                                                                         when received. All other Respondents, including
                                                                         individuals, must be served as required by the California
"Kaiser Permanente Parties" include:
                                                                         Code of Civil Procedure for a civil action.
• Kaiser Foundation Health Plan, Inc.
• Kaiser Foundation Hospitals                                            Filing fee
                                                                         The Claimants shall pay a single, nonrefundable filing
• KP Cal, LLC
                                                                         fee of $150 per arbitration payable to "Arbitration
• The Permanente Medical Group, Inc.                                     Account" regardless of the number of claims asserted in
• Southern California Permanente Medical Group                           the Demand for Arbitration or the number of Claimants
                                                                         or Respondents named in the Demand for Arbitration.
• The Permanente Federation, LLC
• The Permanente Company, LLC                                            Any Claimant who claims extreme hardship may request
• Any Kaiser Foundation Hospitals, The Permanente                        that the Office of the Independent Administrator waive
  Medical Group, Inc., or Southern California                            the filing fee and the neutral arbitrator's fees and
  Permanente Medical Group physician                                     expenses. A Claimant who seeks such waivers shall
                                                                         complete the Fee Waiver Form and submit it to the
                                                                         Office of the Independent Administrator and


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 47
You may qualify for IMR if all of the following are true:            cover than the therapy being requested. "Life-
• One of these situations applies to you:                            threatening" means diseases or conditions where the
                                                                     likelihood of death is high unless the course of the
   ♦ you have a recommendation from a provider                       disease is interrupted, or diseases or conditions with
       requesting Medically Necessary Services                       potentially fatal outcomes where the end point of
   ♦ you have received Emergency Services,                           clinical intervention is survival. "Seriously
       emergency ambulance Services, or Urgent Care                  debilitating" means diseases or conditions that cause
       from a provider who determined the Services to be             major irreversible morbidity
       Medically Necessary
                                                                  • If your treating physician is a Plan Physician, he or
   ♦ you have been seen by a Plan Provider for the                  she recommended a treatment, drug, device,
       diagnosis or treatment of your medical condition             procedure, or other therapy and certified that the
• Your request for payment or Services has been                     requested therapy is likely to be more beneficial to
  denied, modified, or delayed based in whole or in part            you than any available standard therapies and
  on a decision that the Services are not Medically                 included a statement of the evidence relied upon by
  Necessary                                                         the Plan Physician in certifying his or her
                                                                    recommendation
• You have filed a grievance and we have denied it or
  we haven't made a decision about your grievance                 • You (or your Non–Plan Physician who is a licensed,
  within 30 days (or three days for expedited                       and either a board-certified or board-eligible,
  grievances). The Department of Managed Health                     physician qualified in the area of practice appropriate
  Care may waive the requirement that you first file a              to treat your condition) requested a therapy that,
  grievance with us in extraordinary and compelling                 based on two documents from the medical and
  cases, such as severe pain or potential loss of life,             scientific evidence, as defined in California Health
  limb, or major bodily function                                    and Safety Code Section 1370.4(d), is likely to be
                                                                    more beneficial for you than any available standard
You may also qualify for IMR if the Service you                     therapy. The physician's certification included a
requested has been denied on the basis that it is                   statement of the evidence relied upon by the
experimental or investigational as described under                  physician in certifying his or her recommendation.
"Experimental or investigational denials."                          We do not cover the Services of the Non–Plan
                                                                    Provider
If the Department of Managed Health Care determines
that your case is eligible for IMR, it will ask us to send        Note: You can request IMR for experimental or
your case to the Department of Managed Health Care's              investigational denials at any time without first filing a
Independent Medical Review organization. The                      grievance with us.
Department of Managed Health Care will promptly
notify you of its decision after it receives the
Independent Medical Review organization's                         Binding Arbitration
determination. If the decision is in your favor, we will          For all claims subject to this "Binding Arbitration"
contact you to arrange for the Service or payment.                section, both Claimants and Respondents give up the
                                                                  right to a jury or court trial and accept the use of binding
Experimental or investigational denials                           arbitration. Insofar as this "Binding Arbitration" section
If we deny a Service because it is experimental or                applies to claims asserted by Kaiser Permanente Parties,
investigational, we will send you our written explanation         it shall apply retroactively to all unresolved claims that
within five days of making our decision. We will explain          accrued before the effective date of this Membership
why we denied the Service and provide additional                  Agreement and Evidence of Coverage. Such retroactive
dispute resolution options. Also, we will provide                 application shall be binding only on the Kaiser
information about your right to request Independent               Permanente Parties.
Medical Review if we had the following information
when we made our decision:                                        Scope of arbitration
• Your treating physician provided us a written                   Any dispute shall be submitted to binding arbitration
  statement that you have a life-threatening or seriously         if all of the following requirements are met:
  debilitating condition and that standard therapies have         • The claim arises from or is related to an alleged
  not been effective in improving your condition, or                violation of any duty incident to or arising out of or
  that standard therapies would not be appropriate, or              relating to this Membership Agreement and Evidence
  that there is no more beneficial standard therapy we              of Coverage or a Member Party's relationship to


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                             Page 46
simultaneously serve it upon the Respondents. The Fee             of Procedure may be obtained from our Member Service
Waiver Form sets forth the criteria for waiving fees and          Call Center.
is available by calling our Member Service Call Center.
                                                                  General provisions
Number of arbitrators                                             A claim shall be waived and forever barred if (1) on the
The number of arbitrators may affect the Claimant's               date the Demand for Arbitration of the claim is served,
responsibility for paying the neutral arbitrator's fees and       the claim, if asserted in a civil action, would be barred as
expenses.                                                         to the Respondents served by the applicable statute of
                                                                  limitations, (2) Claimants fail to pursue the arbitration
If the Demand for Arbitration seeks total damages of              claim in accord with the Rules of Procedure with
$200,000 or less, the dispute shall be heard and                  reasonable diligence, or (3) the arbitration hearing is not
determined by one neutral arbitrator, unless the parties          commenced within five years after the earlier of (a) the
otherwise agree in writing that the arbitration shall be          date the Demand for Arbitration was served in accord
heard by two party arbitrators and one neutral arbitrator.        with the procedures prescribed herein, or (b) the date of
The neutral arbitrator shall not have authority to award          filing of a civil action based upon the same incident,
monetary damages that are greater than $200,000.                  transaction, or related circumstances involved in the
                                                                  claim. A claim may be dismissed on other grounds by the
If the Demand for Arbitration seeks total damages of              neutral arbitrator based on a showing of a good cause.
more than $200,000, the dispute shall be heard and                If a party fails to attend the arbitration hearing after
determined by one neutral arbitrator and two party                being given due notice thereof, the neutral arbitrator may
arbitrators, one jointly appointed by all Claimants and           proceed to determine the controversy in the party's
one jointly appointed by all Respondents. Parties who are         absence.
entitled to select a party arbitrator may agree to waive
this right. If all parties agree, these arbitrations will be      The California Medical Injury Compensation Reform
heard by a single neutral arbitrator.                             Act of 1975 (including any amendments thereto),
                                                                  including sections establishing the right to introduce
Payment of arbitrators' fees and expenses                         evidence of any insurance or disability benefit payment
Health Plan will pay the fees and expenses of the neutral         to the patient, the limitation on recovery for
arbitrator under certain conditions as set forth in the           noneconomic losses, and the right to have an award for
Rules for Kaiser Permanente Member Arbitrations                   future damages conformed to periodic payments, shall
Overseen by the Office of the Independent Administrator           apply to any claims for professional negligence or any
("Rules of Procedure"). In all other arbitrations, the fees       other claims as permitted or required by law.
and expenses of the neutral arbitrator shall be paid one-
half by the Claimants and one-half by the Respondents.            Arbitrations shall be governed by this "Binding
                                                                  Arbitration" section, Section 2 of the Federal Arbitration
If the parties select party arbitrators, Claimants shall be       Act, and the California Code of Civil Procedure
responsible for paying the fees and expenses of their             provisions relating to arbitration that are in effect at the
party arbitrator and Respondents shall be responsible for         time the statute is applied, together with the Rules of
paying the fees and expenses of their party arbitrator.           Procedure, to the extent not inconsistent with this
                                                                  "Binding Arbitration" section.
Costs
Except for the aforementioned fees and expenses of the
neutral arbitrator, and except as otherwise mandated by           Termination of Membership
laws that apply to arbitrations under this "Binding
Arbitration" section, each party shall bear the party's own       Your membership termination date is the first day you
attorneys' fees, witness fees, and other expenses incurred        are not covered (for example, if your termination date is
in prosecuting or defending against a claim regardless of         January 1, 2011, your last minute of coverage was at
the nature of the claim or outcome of the arbitration.            11:59 p.m. on December 31, 2010). You will be billed as
                                                                  a non-Member for any Services you receive after your
Rules of Procedure                                                membership terminates. When your membership
Arbitrations shall be conducted according to the Rules of         terminates, Health Plan and Plan Providers have no
Procedure developed by the Office of the Independent              further liability or responsibility under this Membership
Administrator in consultation with Kaiser Permanente              Agreement and Evidence of Coverage, except as
and the Arbitration Oversight Board. Copies of the Rules          provided under "Payments after Termination" in this
                                                                  "Termination of Membership" section.


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                            Page 48
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

How You May Terminate Your                                               If we terminate your membership for cause, you will not
Membership                                                               be allowed to enroll in Health Plan in the future. We may
                                                                         also report criminal fraud and other illegal acts to the
You may terminate your membership by sending written                     authorities for prosecution.
notice, signed by the Subscriber, to the address below.
Your membership will terminate at 11:59 p.m. on the last
day of the month in which we receive your notice. Also,                 Termination for Nonpayment of
you must include with your notice all amounts payable                   Premiums
related to this Membership Agreement and Evidence of
Coverage, including Premiums, for the period prior to                    If we terminate this Membership Agreement and
your termination date.                                                   Evidence of Coverage because we did not receive the
                                                                         required Premiums when due, then the membership of
      Kaiser Foundation Health Plan, Inc.
                                                                         the Subscriber will end retroactively at 11:59 p.m. on the
      California Service Center
                                                                         last day of the most recent month for which we received
      P.O. Box 23127
                                                                         a full Premium payment. This retroactive period will not
      San Diego, CA 92193-3127
                                                                         exceed 60 days before the date we mail the Subscriber a
                                                                         notice confirming termination of membership (a
Termination Due to Loss of Eligibility                                   "Termination Notice").

If you meet the eligibility requirements described under                 If we do not receive full Premium payment on or before
"Who Is Eligible" in the "Premiums, Eligibility, and                     the 20th day of the coverage month, we will send a
Enrollment" section on the first day of a month, but later               notice of nonreceipt of payment (a "Late Notice") to the
in that month you no longer meet those eligibility                       Subscriber's address of record. This Late Notice will
requirements, your membership will end at 11:59 p.m. on                  include the following information:
the last day of that month. For example, if you become                   • A statement that we have not received full Premium
ineligible on December 5, 2010, your termination date is                   payment and that we will terminate this Membership
January 1, 2011, and your last minute of coverage is at                    Agreement and Evidence of Coverage for
11:59 p.m. on December 31, 2010.                                           nonpayment if we do not receive the required
                                                                           Premiums within 30 days after the date we mailed the
                                                                           Late Notice
Termination for Cause
                                                                         • The specific date and time when the membership of
If you commit one of the following acts, we may                            the Subscriber will end if we do not receive the
terminate your membership immediately by sending                           required Premiums
written notice to the Subscriber; termination will be
effective on the date we send the notice:                                We will mail a Termination Notice to the Subscriber's
• You intentionally commit fraud in connection with                      address of record if we do not receive full Premium
  membership, Health Plan, or a Plan Provider. Some                      payment within 30 days after the date we mailed the Late
  examples of fraud include:                                             Notice. The Termination Notice will include the
   ♦ misrepresenting eligibility information about you
                                                                         following information:
       or a Dependent                                                    • A statement that we have terminated this Membership
   ♦ presenting an invalid prescription or physician                       Agreement and Evidence of Coverage for
       order                                                               nonpayment of Premiums
   ♦ misusing a Kaiser Permanente ID card (or letting                    • The specific date and time when the membership of
       someone else use it)                                                the Subscriber ended
   ♦ giving us incorrect or incomplete material                          • Information explaining whether or not the Subscriber
       information                                                         can reinstate this Membership Agreement and
   ♦ failing to notify us of changes in family status or                   Evidence of Coverage
       Medicare coverage that may affect your eligibility
       or benefits                                                       Reinstatement after termination for nonpayment
                                                                         of Premiums
After your first 24 months of individuals and families                   Persons terminated for nonpayment of Premiums may
coverage, we may not terminate you for cause solely                      not enroll in Health Plan even after paying all amounts
because you gave us incorrect or incomplete material                     owed unless we approve the enrollment.
information in your Health Coverage Application.


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 49
If we terminate this Membership Agreement and                     "Department of Managed Health Care Complaints" in the
Evidence of Coverage for nonpayment of Premiums, we               "Dispute Resolution" section).
will permit reinstatement of this Membership Agreement
and Evidence of Coverage three times during any 12-
month period if we receive the amounts owed within 15
days of the date of the Late Notice. We will not reinstate
                                                                  Miscellaneous Provisions
this Membership Agreement and Evidence of Coverage
if you do not obtain reinstatement of your terminated             Administration of this Membership Agreement
Membership Agreement and Evidence of Coverage                     and Evidence of Coverage
within the required 15 days, or if we terminate the               We may adopt reasonable policies, procedures, and
Membership Agreement and Evidence of Coverage for                 interpretations to promote orderly and efficient
nonpayment of Premiums more than three times in a 12-             administration of this Membership Agreement and
month period.                                                     Evidence of Coverage.

                                                                  Advance directives
Termination for Discontinuance of a                               The California Health Care Decision Law offers several
Product                                                           ways for you to control the kind of health care you will
                                                                  receive if you become very ill or unconscious, including
We may terminate your membership if we discontinue                the following:
offering this product as permitted or required by law.
                                                                  • A Power of Attorney for Health Care lets you name
If we continue to offer other individual (nongroup)
                                                                    someone to make health care decisions for you when
products, we may terminate your membership under this
                                                                    you cannot speak for yourself. It also lets you write
product by sending you written notice at least 90 days
                                                                    down your own views on life support and other
before the termination date. You will be able to enroll in
                                                                    treatments
any other product we are then offering in the individual
(nongroup) market if you meet all eligibility                     • Individual health care instructions let you express
requirements (except for any medical review                         your wishes about receiving life support and other
requirement). If we discontinue offering all individual             treatment. You can express these wishes to your
(nongroup) products, we may terminate your                          doctor and have them documented in your medical
membership by sending you written notice at least 180               chart, or you can put them in writing and have that
days before the termination date.                                   included in your medical chart

                                                                  To learn more about advance directives, including how
Payments after Termination                                        to obtain forms and instructions, contact your local
                                                                  Member Services Department at a Plan Facility. You can
If we terminate your membership for cause or for
                                                                  also refer to Your Guidebook for more information about
nonpayment, we will:
                                                                  advance directives.
• Within 30 days, refund any amounts we owe for
  Premiums you paid after the termination date                    Membership Agreement and Evidence of
• Pay you any amounts we have determined that we                  Coverage binding on Members
  owe you for claims during your membership in                    By electing coverage or accepting benefits under this
  accord with the "Emergency Services and Urgent                  Membership Agreement and Evidence of Coverage, all
  Care" and "Dispute Resolution" sections                         Members legally capable of contracting, and the legal
                                                                  representatives of all Members incapable of contracting,
We will deduct any amounts you owe Health Plan or                 agree to all provisions of this Membership Agreement
Plan Providers from any payment we make to you.                   and Evidence of Coverage.

                                                                  Applications and statements
State Review of Membership                                        You must complete any applications, forms, or
Termination                                                       statements that we request in our normal course of
                                                                  business or as specified in this Membership Agreement
If you believe that we terminated your membership                 and Evidence of Coverage.
because of your ill health or your need for care, you may
request a review of the termination by the California             Assignment
Department of Managed Health Care (please see                     You may not assign this Membership Agreement and
                                                                  Evidence of Coverage or any of the rights, interests,


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                          Page 50
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
claims for money due, benefits, or obligations hereunder                 sexual orientation, physical or mental disability, or
without our prior written consent.                                       genetic information.

Attorney and advocate fees and expenses                                  Notices
In any dispute between a Member and Health Plan, the                     Our notices to you will be sent to the most recent address
Medical Group, or Kaiser Foundation Hospitals, each                      we have for the Subscriber, except that if the Subscriber
party will bear its own fees and expenses, including                     has chosen to receive these membership agreement and
attorneys' fees, advocates' fees, and other expenses.                    evidence of coverage documents online we will notify
                                                                         the Subscriber at the most recent email address we have
Claims review authority                                                  for the Subscriber when notices related to amendment of
We are responsible for determining whether you are                       this Membership Agreement and Evidence of Coverage
entitled to benefits under this Membership Agreement                     are posted on our website at kp.org. The Subscriber is
and Evidence of Coverage and we have the discretionary                   responsible for notifying us of any change in address.
authority to review and evaluate claims that arise under                 Subscribers who move (or change their e-mail address if
this Membership Agreement and Evidence of Coverage.                      the Subscriber has chosen to receive these membership
We conduct this evaluation independently by interpreting                 agreement and evidence of coverage documents on our
the provisions of this Membership Agreement and                          website) should call our Member Service Call Center as
Evidence of Coverage. If coverage under this                             soon as possible to give us their new address. If a
Membership Agreement and Evidence of Coverage is                         Member does not reside with the Subscriber, he or she
subject to the Employee Retirement Income Security Act                   should contact our Member Service Call Center to
(ERISA) claims procedure regulation (29 CFR 2560.503-                    discuss alternate delivery options.
1), then we are a "named claims fiduciary" to review
claims under this Membership Agreement and Evidence                      Other formats for Members with disabilities
of Coverage.                                                             You can request a copy of this Membership Agreement
                                                                         and Evidence of Coverage in an alternate format (Braille,
Governing law                                                            audio, electronic text file, or large print) by calling our
Except as preempted by federal law, this Membership                      Member Service Call Center.
Agreement and Evidence of Coverage will be governed
in accord with California law and any provision that is                  Overpayment recovery
required to be in this Membership Agreement and                          We may recover any overpayment we make for Services
Evidence of Coverage by state or federal law shall bind                  from anyone who receives such an overpayment or from
Members and Health Plan whether or not set forth in this                 any person or organization obligated to pay for the
Membership Agreement and Evidence of Coverage.                           Services.

Health Insurance Counseling and Advocacy                                 Privacy practices
Program (HICAP)                                                          Kaiser Permanente will protect the privacy of your
For additional information concerning benefits, contact                  protected health information. We also require contracting
the Health Insurance Counseling and Advocacy Program                     providers to protect your protected health information.
(HICAP) or your agent. HICAP provides health                             Your protected health information is individually-
insurance counseling for California senior citizens. Call                identifiable information (oral, written, or electronic)
HICAP toll free at 1-800-434-0222 (TTY users call 711)                   about your health, health care services you receive, or
for a referral to your local HICAP office. HICAP is a                    payment for your health care. You may generally see and
free service provided by the state of California.                        receive copies of your protected health information,
                                                                         correct or update your protected health information, and
No waiver                                                                ask us for an accounting of certain disclosures of your
Our failure to enforce any provision of this Membership                  protected health information.
Agreement and Evidence of Coverage will not constitute
a waiver of that or any other provision, or impair our                   We may use or disclose your protected health
right thereafter to require your strict performance of any               information for treatment, health research, payment, and
provision.                                                               health care operations purposes, such as measuring the
                                                                         quality of Services. We are sometimes required by law to
Nondiscrimination                                                        give protected health information to others, such as
We do not discriminate in our employment practices or                    government agencies or in judicial actions. We will not
in the delivery of Services on the basis of age, race,                   use or disclose your protected health information for any
color, national origin, cultural background, religion, sex,              other purpose without your (or your representative's)



Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 51
written authorization, except as described in our Notice          How to Reach Us
of Privacy Practices (see below). Giving us authorization
is at your discretion.                                            Appointments
                                                                  If you need to make an appointment, please call us or
This is only a brief summary of some of our key                   visit our website:
privacy practices. Our Notice of Privacy Practices,
which provides additional information about our                   Call           The appointment phone number at a
privacy practices and your rights regarding your                                 Plan Facility (refer to Your Guidebook
protected health information is available and will be                            or the facility directory on our website
furnished to you upon request. To request a copy,                                at kp.org for phone numbers)
please call our Member Service Call Center. You can
                                                                  Website        kp.org for routine (non-urgent)
also find the notice at your local Plan Facility or on
                                                                                 appointments with your personal Plan
our website at kp.org.
                                                                                 Physician or another Primary Care
                                                                                 Physician
Public policy participation
The Kaiser Foundation Health Plan, Inc., Board of                 Not sure what kind of care you need?
Directors establishes public policy for Health Plan. A list
                                                                  If you need advice on whether to get medical care, or
of the Board of Directors is available on our website at
                                                                  how and when to get care, we have licensed health care
kp.org or from our Member Service Call Center. If you
                                                                  professionals available to assist you by phone 24 hours a
would like to provide input about Health Plan public
                                                                  day, 7 days a week:
policy for consideration by the Board, please send
written comments to:
                                                                  Call           The appointment or advice phone
     Kaiser Foundation Health Plan, Inc.                                         number at a Plan Facility (refer to Your
     Office of Board and Corporate Governance Services                           Guidebook or the facility directory on
     One Kaiser Plaza, 19th Floor                                                our website at kp.org for phone
     Oakland, CA 94612                                                           numbers)
Telephone access (TTY)                                            Member Services
If you are hearing or speech impaired and use a text              If you have questions or concerns about your coverage,
telephone device (TTY, also known as TDD) to                      how to obtain Services, or the facilities where you can
communicate by phone, you can use the California Relay            receive care, you can reach us by calling, writing, or
Service by calling 711 if a dedicated TTY number is not           visiting our website:
available for the telephone number that you want to call.
                                                                  Call           1-800-464-4000
                                                                                 1-800-390-3510 (TTY)
Helpful Information
                                                                                 Weekdays 7 a.m. to 7 p.m., and
                                                                                 weekends 7 a.m. to 3 p.m. (except
Your Guidebook to Kaiser Permanente
                                                                                 holidays)
Services (Your Guidebook)
                                                                  Write          Member Services Department at a Plan
Please refer to Your Guidebook for helpful information                           Facility (refer to Your Guidebook for
about your coverage, such as:                                                    addresses)
• The types of covered Services that are available from           Website        kp.org
  each Plan Facility in your area
• How to use our Services and make appointments                   Authorization for Post-Stabilization Care
• Hours of operation                                              If you need to request authorization for Post-Stabilization
                                                                  Care as described under "Emergency Services" in the
• Appointments and advice phone numbers                           "Emergency Services and Urgent Care" section, please
                                                                  call us:
You can get a copy of Your Guidebook by visiting our
website at kp.org or by calling our Member Service Call           Call          1-800-225-8883 or the notification
Center.                                                                         telephone number on your Kaiser
                                                                                Permanente ID card




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 52
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

                                                                         • If you receive Emergency Services, Post-Stabilization
                711 (TTY)
                                                                           Care, or Out-of-Area Urgent Care from a Non–Plan
                Call any time                                              Provider, or if you receive emergency ambulance
                                                                           Services, you must pay the provider and file a claim
Help with claim forms for Emergency Services,                              for reimbursement unless the provider agrees to bill
Post-Stabilization Care, Out-of-Area Urgent                                us (refer to "Payment and Reimbursement" in the
Care, and emergency ambulance Services                                     "Emergency Services and Urgent Care" section)
If you need a claim form to request payment or                           • If you receive Services from Non–Plan Providers that
reimbursement for Services described in the "Emergency                     we did not authorize (other than Emergency Services,
Services and Urgent Care" section or under "Ambulance                      Post-Stabilization Care, Out-of-Area Urgent Care, or
Services" in the "Benefits and Cost Sharing" section, or                   emergency ambulance Services) and you want us to
if you need help completing the form, you can reach us                     pay for the care, you must submit a grievance (refer
by calling or by visiting our website.                                     to "Grievances" in the "Dispute Resolution" section)
                                                                         • If you have Medicare, we will coordinate benefits
Call            1-800-464-4000 or 1-800-390-3510                           with the other coverage (refer to "Coordination of
                1-800-777-1370 (TTY)                                       Benefits" in the "Exclusions, Limitations,
                                                                           Coordination of Benefits, and Reductions" section)
                Weekdays 7 a.m. to 7 p.m., and
                weekends 7 a.m. to 3 p.m. (except                        • In some situations, you or a third party may be
                holidays)                                                  responsible for reimbursing us for covered Services
                                                                           (refer to "Reductions" in the "Exclusions,
Website         kp.org                                                     Limitations, Coordination of Benefits, and
                                                                           Reductions" section)
Submitting claims for Emergency Services,
                                                                         • You are responsible for paying the full price for
Post-Stabilization Care, Out-of-Area Urgent
                                                                           noncovered Services
Care, and emergency ambulance Services
If you need to submit a completed claim form for
Services described in the "Emergency Services and
Urgent Care" section or under "Ambulance Services" in                   Chiropractic Services Amendment
the "Benefits and Cost Sharing" section, or if you need to
submit other information that we request about your                      This "Chiropractic Services Amendment" amends
claim, send it to our Claims Department:                                 your Individual Plan Membership Agreement and
                                                                         Disclosure Form and Evidence of Coverage for Kaiser
Write           Kaiser Foundation Health Plan, Inc.                      Permanente Individual—Conversion Plan to include
                Claims Department                                        coverage for Medically Necessary Chiropractic
                P.O. Box 7004                                            Services under the following terms and conditions.
                Downey, CA 90242-7004
                                                                         All provisions of the Membership Agreement and
                                                                         Evidence of Coverage apply to coverage described in this
Payment Responsibility                                                   document except for the following sections:
This "Payment Responsibility" section briefly explains                   • "How to Obtain Services" (except that the
who is responsible for payments related to the health care                 "Completion of Services from Non–Plan Providers"
coverage described in this Membership Agreement and                        or for Kaiser Permanente Senior Advantage or
Evidence of Coverage. Payment responsibility is more                       Medicare Cost Members, the "Termination of a Plan
fully described in other sections of the Membership                        Provider's contract and completion of Services"
Agreement and Evidence of Coverage as described                            section does apply to coverage described in this
below:                                                                     document)
• The Subscriber is responsible for paying Premiums                      • "Plan Facilities"
  (refer to "Premiums" in the "Premiums, Eligibility,                    • "Emergency Services and Urgent Care"
  and Enrollment" section)
                                                                         • "Benefits and Cost Sharing" (except that the "Annual
• You are responsible for paying Cost Sharing for                          out-of-pocket maximum" section does apply to
  covered Services (refer to "Cost Sharing" in the                         coverage described in this document)
  "Benefits and Cost Sharing" section)




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 53
Kaiser Foundation Health Plan, Inc. contracts with                Member Services Department toll free at
American Specialty Health Plans of California, Inc.               1-800-678-9133 (TTY users call 711). The list of
(ASH Plans) to make the ASH Plans network of                      Participating Chiropractors is subject to change at any
Participating Chiropractors available to you. When you            time, without notice. If you have questions, please call
need chiropractic care, you have direct access to more            the ASH Plans Member Services Department.
than 2,800 licensed chiropractors in California. You can
obtain covered Services from any Participating                    Participating Provider: A Participating Chiropractor or
Chiropractor without a referral from a Plan Physician.            any licensed provider with which ASH Plans contracts to
Cost Sharing is due when you receive covered Services.            provide covered care, including laboratory tests or X-
                                                                  rays that are covered chiropractic care.

Definitions                                                       Treatment Plan: A proposed course of treatment for
                                                                  your Neuromusculoskeletal Disorder, which may include
In addition to the terms defined in the "Definitions"
                                                                  laboratory tests, X-rays, chiropractic appliances, and a
section of your Health Plan Membership Agreement and
                                                                  specific number of visits for chiropractic manipulations,
Evidence of Coverage, the following terms, when
                                                                  adjustments, and therapies that are Medically Necessary
capitalized and used in any part of this "Chiropractic
                                                                  Chiropractic Services for you.
Services Amendment" have the following meaning:

Chiropractic Services: Chiropractic Services provided             Participating Providers
or prescribed by a chiropractor (including laboratory
tests, X-rays, and chiropractic appliances) for the               Please read the following information so you will
treatment of your Neuromusculoskeletal Disorder.                  know from whom or what group of providers you
                                                                  may receive covered chiropractic services.
Emergency Chiropractic Services: Covered
Chiropractic Services provided for the treatment of a             ASH Plans contracts with Participating Chiropractors
sudden and unexpected onset of a Neuromusculoskeletal             and other Participating Providers to provide covered
Disorder which manifests itself by acute symptoms of              Chiropractic Services (including laboratory tests, X-rays,
sufficient severity (including severe pain) such that you         and chiropractic appliances). You must receive Services
could reasonably expect the absence of immediate                  covered under this "Chiropractic Services Amendment"
Chiropractic Services to result in serious jeopardy to            from a Participating Provider, except for Emergency
your health or body functions or organs.                          Chiropractic Services and Services that are not available
                                                                  from Participating Providers that are authorized in
Neuromusculoskeletal Disorders: Conditions with                   advance by ASH Plans.
associated signs and symptoms related to the nervous,
muscular, or skeletal systems. Neuromusculoskeletal               How to obtain Services
Disorders are conditions typically categorized as                 To obtain Services covered under this "Chiropractic
structural, degenerative, or inflammatory disorders, or           Services Amendment," call a Participating Chiropractor
biomechanical dysfunction of the joints of the body or            to schedule an initial examination. If additional Services
related components of the motor unit (muscles, tendons,           are required, your Participating Chiropractor will prepare
fascia, nerves, ligaments/capsules, discs, and synovial           a Treatment Plan. The ASH Plans Clinical Services
structures), and related neurological manifestations or           Manager will authorize the Treatment Plan if the
conditions.                                                       Services are Medically Necessary Chiropractic Services
                                                                  for you. ASH Plans will disclose to you, upon request,
Non–Participating Chiropractor: A chiropractor other              the process that it uses to authorize a Treatment Plan. If
than a Participating Chiropractor.                                you have questions or concerns, please contact ASH
                                                                  Plans or Kaiser Permanente as described under "Member
Non–Participating Provider: A provider other than a               Services" in this "Chiropractic Services Amendment."
Participating Provider.

Participating Chiropractor: A chiropractor who is                 Covered Services
licensed to provide chiropractic services in California
                                                                  We cover the Services listed in this "Covered Services"
and who has a contract with ASH Plans to provide
                                                                  section, subject to exclusions described under
Medically Necessary Chiropractic Services to you. A list
                                                                  "Exclusions" in the "Exclusions and Limitations"
of Participating Chiropractors is available on the ASH
Plans website at ashplans.com or from the ASH Plans


Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 54
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)
section, only if all of the following conditions are                     Office visits
satisfied:                                                               We cover up to a combined total of 20 of the following
• You are a Member on the date that you receive the                      types of office visits per calendar year at a
  Services                                                               $15 Copayment per visit:
• The Services are Medically Necessary                                   • Chiropractic office visits. Each office visit counts
                                                                           toward the calendar year visit limit even if an
• ASH Plans has authorized the Services as part of your                    adjustment is not provided during the visit:
  Treatment plan, except for:
                                                                            ♦ Initial examination: An examination performed
   ♦ the initial examination described under "Office
                                                                              by a Participating Chiropractor to determine the
       Visits" in this "Covered Services" section                             nature of your problem (and, if appropriate, to
   ♦ Emergency Chiropractic Services described under                          prepare a Treatment Plan), and to provide
       "Emergency Chiropractic Services" in this                              Medically Necessary Chiropractic Services, which
       "Covered Services" section                                             may include an adjustment and adjunctive therapy
• You receive the Services from Participating                                 (such as ultrasound, hot packs, cold packs, or
  Providers, except for:                                                      electrical muscle stimulation). We cover an initial
                                                                              examination only if you have not already received
   ♦ Emergency Chiropractic Services described under
                                                                              covered Services from a Participating Chiropractor
       "Emergency Chiropractic Services" in this
                                                                              in the same calendar year for your
       "Covered Services" section
                                                                              Neuromusculoskeletal Disorder
   ♦ Services that are not available from Participating
                                                                            ♦ Subsequent office visits: Subsequent
       Providers that are authorized in advance by ASH
                                                                              Participating Chiropractor office visits for
       Plans
                                                                              Medically Necessary Chiropractic Services, which
                                                                              may include an adjustment, adjunctive therapy,
Covered Services are provided at the Cost Sharing listed
                                                                              and a re-examination to assess the need to
in this "Covered Services" section. However, you may be
                                                                              continue, extend, or change a Treatment Plan
liable for the cost of noncovered services you obtain
from Participating Providers or Non–Participating
                                                                         Laboratory tests and X-rays
Providers.
                                                                         We cover Medically Necessary laboratory tests and X-
                                                                         rays when prescribed as part of covered chiropractic care
The Cost Sharing you pay for Services covered under
                                                                         described under "Office visits" in this "Covered
this "Chiropractic Services Amendment" does not apply
                                                                         Services" section at no charge when a Participating
toward the annual out-of-pocket maximum described in
                                                                         Chiropractor provides the Services or refers you to a
your Health Plan Membership Agreement and Evidence
                                                                         Participating Provider for the Services.
of Coverage.
                                                                         Chiropractic appliances
Coverage of chiropractic Services under this
                                                                         We provide a $50 Allowance per calendar year toward
"Chiropractic Services Amendment" is different from the
                                                                         the ASH Plans fee schedule price for chiropractic
coverage of chiropractic Services under "Outpatient
                                                                         appliances listed in this paragraph when the item is
Care" in the "Benefits and Cost Sharing" section of the
                                                                         prescribed and provided to you by a Participating
Membership Agreement and Evidence of Coverage. You
                                                                         Chiropractor as part of covered chiropractic care
do not need a referral to get covered Services under this
                                                                         described under "Office visits" in this "Covered
"Chiropractic Services Amendment," but covered
                                                                         Services" section. If the price of the item(s) in the ASH
Services and Cost Sharing may differ from those under
                                                                         Plans fee schedule exceeds $50 (the Allowance), you
"Outpatient Care" in the "Benefits and Cost Sharing"
                                                                         will pay the amount in excess of $50 (and that payment
section of the Membership Agreement and Evidence of
                                                                         does not apply toward your annual out-of-pocket
Coverage. If you receive chiropractic Services for which
                                                                         maximum). Covered chiropractic appliances are limited
you have a referral, as described under "Getting a
                                                                         to: elbow supports, back supports (thoracic), cervical
Referral" in the "How to Obtain Services" section of the
                                                                         collars, cervical pillows, heel lifts, hot or cold packs,
Membership Agreement and Evidence of Coverage, then
                                                                         lumbar braces and supports, lumbar cushions, orthotics,
unless you tell us otherwise, we will assume that you are
                                                                         wrist supports, rib belts, home traction units (cervical or
using your coverage under "Outpatient Care" in the
                                                                         lumbar), ankle braces, knee braces, rib supports, and
"Benefits and Cost Sharing" section of the Membership
                                                                         wrist braces.
Agreement and Evidence of Coverage.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 55
Second opinions                                                   • Services for asthma or addiction, such as nicotine
If you request a second opinion, it will be provided to             addiction
you by a Participating Chiropractor who is an                     • Hypnotherapy, behavior training, sleep therapy, and
appropriately qualified chiropractor (a chiropractor who            weight programs
is acting within his or her scope of practice and who
possesses a clinical background related to the illness or         • Thermography
condition associated with the request for a second                • Experimental or investigational Services. Please refer
opinion). To get a second opinion, make an appointment              to the "Dispute Resolution" section in your Health
with a Participating Chiropractor. Second opinion office            Plan Membership Agreement and Evidence of
visits are provided at a $15 Copayment per visit and                Coverage for information about Independent Medical
count toward your annual visit limit unless a                       Review related to denied requests for Medically
Participating Chiropractor refers you to another                    Necessary and experimental or investigational
Participating Chiropractor for a consultation that does             Services
not include treatment. If ASH Plans determines that there
                                                                  • MRI, CT, PET, bone scans, nuclear radiology, and
isn't a Participating Chiropractor who is an appropriately
                                                                    any types of diagnostic radiology other than X-rays
qualified chiropractor for your condition, ASH Plans will
                                                                    covered under the "Covered Services" section of this
authorize a referral to a Non–Participating Chiropractor
                                                                    "Chiropractic Services Amendment"
for a second opinion.
                                                                  • Ambulance and other transportation
Emergency Chiropractic Services                                   • Education programs, non-medical self-care or self-
Emergency Chiropractic Services. We cover                           help, any self-help physical exercise training, and any
Emergency Chiropractic Services provided by a                       related diagnostic testing
Participating Chiropractor or a Non–Participating
                                                                  • Services for pre-employment physicals or vocational
Chiropractor at a $15 Copayment per visit. We do not
                                                                    rehabilitation
cover follow-up or continuing care from a Non–
Participating Chiropractor unless ASH Plans has                   • Air conditioners, air purifiers, therapeutic mattresses,
authorized the Services in advance. Also, we do not                 chiropractic appliances, durable medical equipment,
cover Services from a Non-Participating Chiropractor                supplies, devices, appliances, and any other item
that ASH Plans determines are not Emergency                         except those listed as covered under "Chiropractic
Chiropractic Services.                                              appliances" in the "Covered Services" section of this
                                                                    "Chiropractic Services Amendment"
How to file a claim. As soon as possible after receiving          • Drugs and medicines, including non-legend or
Emergency Chiropractic Services, you must file an ASH               proprietary drugs and medicines
Plans claim form. To request a claim form or for more
                                                                  • Services you receive outside the state of California,
information, please call ASH Plans toll free at 1-800-
                                                                    except for Emergency Chiropractic Services
678-9133 (TTY users call 711). You must send the
completed claim form to:                                          • Hospital services, anesthesia, manipulation under
     ASH Plans                                                      anesthesia, and related services
     P.O. Box 509002                                              • For chiropractic services, adjunctive therapy not
     San Diego, CA 92150-9002                                       associated with spinal, muscle, or joint manipulations
                                                                  • Dietary and nutritional supplements, including
Exclusions and Limitations                                          vitamins, minerals, herbs, herbal products, injectable
                                                                    supplements, and similar products
Exclusions                                                        • Massage therapy
The Services listed in this "Exclusions" section are
excluded from coverage. These exclusions apply to all             • Services provided by a chiropractor that are not
Services that would otherwise be covered under this                 within the scope of licensure for a chiropractor
"Chiropractic Services Amendment":                                  licensed in California

• Any Services not provided by a Participating                    • Maintenance care (services provided to Members
  Chiropractor or Participating Provider, except for                whose treatment records indicate he or she has
  Emergency Chiropractic Services, and Services that                reached maximum therapeutic benefit)
  are not available from Participating Providers but that
  are authorized in advance by ASH Plans




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                           Page 56
                                                    Member Service Call Center: toll free 1-800-464-4000 (TTY users call 1-800-777-1370)
                                                                        weekdays 7 a.m.–7 p.m., weekends 7 a.m.–3 p.m. (except holidays)

Member Services
If you have a question or concern regarding the Services
you received from a Participating Provider, you may call
ASH Plans Member Services toll free at 1-800-678-9133
(TTY users call 711) weekdays from 5 a.m. to 6 p.m., or
write ASH Plans at:
     ASH Plans
     Member Services
     P.O. Box 509002
     San Diego, CA 92150-9002


Grievances
You can file a grievance with Kaiser Permanente
regarding any issue. Your grievance must explain your
issue, such as the reasons why you believe a decision
was in error or why you are dissatisfied about Services
you received. You may submit your grievance orally or
in writing to Kaiser Permanente as described in the
"Dispute Resolution" section of your Health Plan
Membership Agreement and Evidence of Coverage.




Kaiser Permanente Individual—Conversion Deductible 30/1500 Plan
Date: September 30, 2010                                                                                                    Page 57
NOTES
           3




kp.org




60067606

								
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