2018 PLAN UPDATES. What s new for Oregon small business group plans OREGON

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1 2018 PLAN UPDATES What s new for Oregon small business group plans OREGON 2018 This booklet contains a summary of important information you will want to know about our 2018 small group plans. For more details on plan design, refer to the Medical Plans Overview for Oregon Small Businesses. account.kp.org _NW-OR_11/17 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR

2 Your partner in good health At Kaiser Permanente, we offer a fully integrated health care delivery system with providers, hospitals, pharmacies, and labs working together to provide coordinated care for our members. What s new at Kaiser Permanente Northwest We are proud to be part of the Greater Portland, Southwest Washington, Salem, and Lane County communities. With 34 medical offices, 20 dental offices, and access to all locations of The Portland Clinic, there s sure to be a clinic convenient to your home, work, or school. Save time, stay comfortable, and get the urgent, primary, or specialty care you need from home, work, or anywhere else on your camera-equipped computer, tablet, or smartphone. If appropriate for your condition, we offer , phone, and video visits. Sign on to kp.org to self-schedule an appointment. Care Essentials by Kaiser Permanente offers a convenient neighborhood clinic in the Pearl District to treat members and nonmembers for common, nonemergency health issues. Schedule an appointment at careessentials.org or Cedar Hills Dental and Medical Office, which opened early 2017, merges dental with an embedded, low-acuity medical capability. Additionally, Kaiser Permanente will continue to expand its dental access points with new offices opening in Johnson Creek and Salem, as well as an expansion at the Clackamas location. Our focus on integrated care helps us provide communication between your medical and dental providers. Our dentists can easily access your relevant health records and communicate with your Kaiser Permanente medical clinicians, so you can rest easier knowing we re looking out for your total health. Vision Essentials by Kaiser Permanente is now open to serve you on Saturdays at Beaverton Medical Office, Cascade Park Medical Office, and Clackamas Eye Care. We have improved the overall level of service and support for our valued Added Choice members by adding a new dedicated Member Services phone line available for questions Monday through Friday, 8 a.m. to 6 p.m., at Oregon group size determinations Oregon insurance regulations are updated on common law employee enrollment requirements as related to employer group eligibility determinations. Before this update, employers may have been able to access the small group market simply by offering coverage to at least one common law employee. The new guidance specifies that to be an eligible small employer, at least one common law employee must be enrolled at the beginning of the plan year. Our new group and pre-renewal group screening processes will be modified accordingly. This change may result in some small business owners needing to obtain coverage through the individual rather than small group market. If a group is identified as being ineligible to renew, we will offer each affected member the opportunity to purchase any of our individual health benefit plans. Note: An employee is considered a common law employee if the employer has the authority to direct and control the manner in which the services are performed by the individual. For more information, see Exhibit A to OAR (search for exhibit at 2

3 2018 medical plan portfolio Our plan portfolio offers choice and flexibility. We have multiple plans to choose from in all 4 metal levels. It was necessary to make changes to certain cost shares on some plans such as the,, copays, and out-of-pocket maximum amounts in order to keep the plans within their metal level and cover a similar percentage of health care costs as the prior year. Two of our plans (KP OR Silver 1500/35 and KP OR Silver 0/50) are being discontinued and replaced with other plan offerings. However, we have added 1 new plan in the Gold metal level (KP OR Gold 1500/35). Read on for a detailed list of specific benefit changes to each plan. Alternative care, routine vision eye exam and hardware benefits This year we will continue to offer many plans outside the Oregon health insurance marketplace with 3 buy-up options: medical plans with self-referred alternative care; medical plans with adult vision hardware and routine exam; and medical plans with both self-referred alternative care, vision hardware and routine eye exam. As a reminder, to offer choice and affordability, plans purchased without the vision hardware benefit do not provide coverage for adult routine eye exams. Automatic renewals For your renewal in 2018, we will automatically provide you with coverage from one of the plans that best matches the plan or plans your business offers today. But you can choose from any of our other plans available to small employers if you prefer. Please indicate on the Renewal Decision Form whether you decide to accept the renewal as offered or make changes. Bundle options As you consider alternatives to lower your health care costs, consider offering employees a plan with 1 or 2 buyup alternatives. These bundle plan options are provided at no additional charge and allow you to tailor your plan offerings, giving employees more choice and more control over their monthly premium cost. You contribute the same amount toward each plan (no less than of the lowest premium plan) and let your employees decide if they want to pay more for a buy-up option. For more details, refer to the Medical Plans Overview for Oregon Small Businesses PLAN HIGHLIGHTS AND REMINDERS Prescription drug coverage is automatically covered on all medical plans All our plans come with built-in coverage for outpatient prescription drugs. All prescription drug plans have a 4-tier benefit design with different cost-sharing amounts for generic, preferred brand, non-preferred brand, and specialty drugs. Your employees can save time and money by ordering prescription refills online or by phone. Members can get a 90-day supply for only twice the 30-day supply copay when we mail your prescription. We can mail most prescription drugs to you within 10 days, and you don t pay any extra cost for standard U.S. postage. 3

4 Pediatric vision coverage on all medical plans All our plans cover pediatric vision exams and 1 pair of standard frames or a 6-month supply of contact lenses, for children 18 and younger, at no additional charge. Pediatric dental services and coverage for your renewal Pediatric dental coverage for members is required by law, so all our medical plans are offered along with an ACA-compliant pediatric dental plan. All 3 of our pediatric dental plans are Dental Choice (PPO) plans, which means you will get a choice of preferred providers, including those in our dental facilities and non-participating dentists. One of the 3 pediatric plans provides coverage for standard orthodontia for misaligned teeth. If you have an ACA-compliant pediatric dental plan offered by another carrier, you may opt out of our coverage by attesting to this fact on your New Group Application or Renewal Decision Form. If your group previously attested to having other ACA-compliant pediatric dental coverage and waived this coverage, you must provide an updated attestation upon renewal using the Renewal Decision Form. If a plan is not selected or an updated attestation received, coverage will be added. Adult-only dental plans All traditional and PPO dental plan designs will continue for adults only (19 and older), and pediatric dental coverage will be provided separately as indicated above. As a reminder, we offer 5 plans that may be purchased with adult cosmetic orthodontia coverage. If you currently offer dental coverage, the same plan will be provided for your automatic renewal. If you want to choose a different plan, you may do so as well. Standard plans Our plan portfolio includes standard plans that have been designed by the state of Oregon, and all carriers are required to offer these particular plans. Because they were not designed by Kaiser Permanente, the coverage may differ slightly from our typical plans. Differences include benefits such as hospice, infertility, reconstructive surgery, and dependent out of area. Please refer to your Sales Summary of Benefits for details. Benefits that accrue to the medical out-of-pocket maximum Most benefits, including copays and for services not subject to, as well as the itself, accrue to the medical out-of-pocket maximum. Copays and that accrue to the out-of-pocket maximum are waived once an individual or family has reached that maximum. Underwriting guidelines Please be sure to review the Rating and Underwriting Assumptions Policy effective January 1, 2018, for Oregon groups with 50 or fewer employees. 4

5 TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE (HSA-QUALIFIED), AND ADDED CHOICE MEDICAL PLANS Small group medical plans Traditional plans Deductible plans HSA-qualified High Deductible Health Plans Added Choice plans PLATINUM GOLD SILVER BRONZE KP OR PLATINUM 0/20 KP OR PLATINUM 250/20 KP OR PLATINUM 250/10 3T POS 1 KP OR PLATINUM 250/10 3T POS OOA 1 KP OR GOLD 0/30 KP OR GOLD 500/20 KP OR GOLD 1000/20 KP OREGON STANDARD GOLD PLAN KP OR GOLD 1500/35 KP OR GOLD 600/35 3T POS 1 KP OR GOLD 600/35 3T POS OOA 1 KP OR GOLD 1000/35 3T POS 1 KP OR GOLD 1000/35 3T POS OOA 1 KP OR SILVER 2000/40 1 KP OREGON STANDARD SILVER PLAN KP OR SILVER 3500/40 KP OR SILVER 2700/ HSA KP OR SILVER 2500/40 3T POS 1 KP OR SILVER 2500/40 3T POS OOA 1 KP OR BRONZE 5000/50 KP OR BRONZE 6600/40 KP OR BRONZE 5200/20 HSA KP OREGON STANDARD BRONZE HSA PLAN Buy-up options 2 Any of the above medical plans, when purchased directly through Kaiser Permanente, can be paired with a buy-up option listed below, with the exception of the Standard plans. A. $200/2-year period vision hardware benefit and routine eye exam B. Alternative Care $20 chiro/natur/acu, $25 massage/$1,000 MAX C. Bundle of option A and B 1 Offered only outside the health insurance marketplace. 2 Buy-up options listed for vision hardware and routine vision exam are for adults. All our plans cover pediatric vision exams and 1 pair of standard frames or a 6-month supply of contact lenses, for children 18 and younger, at no charge. Changes to Kaiser Permanente Senior Advantage plans are explained on page 18 of this document. Standard plan EOSGDEDSTD0118 EOSGHDHPSTD0118 Medical EOC form numbers: EOSGTRAD0118 EOSGHDHP0118 EOSGDED0118 EOSG3TPOSDED0118 5

6 SUMMARY OF CHANGES AND CLARIFICATIONS FOR OREGON SMALL EMPLOYER GROUPS This is a summary of changes and clarifications that we have made to your Group Agreement. The Group Agreement includes the Evidence of Coverage (EOC), Benefit Summary, and any applicable endorsement documents. This summary does not include minor changes and clarifications we are making to improve the readability and accuracy of the Group Agreement. These changes and clarifications do not include changes that may occur throughout the remainder of the year as a result of federal or state mandates. Other group-specific or product-specific plan design changes may apply, such as moving to standard benefits. Refer to the Plan Updates document for information about these types of changes. To the extent that this summary of changes and clarifications conflicts with, modifies, or supplements the information contained in your Group Agreement, the information contained in the Group Agreement shall supersede what is set forth below. Unless another date is listed, the changes in this document are effective when your group renews in The products named below are offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 6

7 CHANGES AND CLARIFICATIONS THAT APPLY TO TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE, AND ADDED CHOICE MEDICAL PLANS Changes to the Senior Advantage plan are explained at the end of this summary. Benefit changes Gender Affirming Treatment. We have added the definition of Gender Affirming Treatment to the Definitions section of the EOC. We have also added Gender Affirming Treatment to the list of covered Services in the Benefits for Outpatient Services and Benefits for Inpatient Services sections of the EOC in accordance with the Oregon Division of Financial Regulation (DFR) Bulletin to insurers. Mental Health Services. The Mental Health Services section of the EOC has been modified to add assertive community treatment to the description of covered outpatient mental health services. Services require a referral and are subject to utilization management. Outpatient Durable Medical Equipment. We have added coverage for wigs following chemotherapy or radiation therapy to the Outpatient Durable Medical Equipment section to align with the Oregon Essential Health Benefits (EHB) outlined in the Base Benchmark Plan. Virtual Care Services. The Virtual Care Services section of the EOC has been modified to include coverage for scheduled telephone visits. Additionally, language has been added to reflect that all virtual care Services are subject to the on High Deductible Health Plans as required for HSA-qualified plans. Benefit clarifications Benefits for Outpatient Services. We have added cochlear implants to the internally implanted devices bullet in the Benefits for Outpatient Services and Benefits for Inpatient Services sections of the EOC. Emergency, Post-Stabilization, and Urgent Care. The Emergency, Post-Stabilization, and Urgent Care section has been modified. Emergency Services and Post-Stabilization Care are subject to the same Copayments or Coinsurance as the same Service, were it not an Emergency or Post-Stabilization, and references to Urgent Care within this description were removed as Urgent Care has a unique cost share, listed on the Benefit Summary. For example, if you receive covered inpatient hospital Services, you pay the Copayment or Coinsurance shown in the Benefit Summary under Inpatient Hospital Services, regardless of whether the Services also constitute Emergency Services or Post-Stabilization Care. High Deductible Health Plan. The High Deductible Health Plan Benefit Summary documents have been modified to ensure language is included on all benefits that are not preventive as required for HSA-qualified plans. Limited Dental Services Exclusions. We have removed the Injuries to teeth resulting from biting or chewing. exclusion from the Limited Dental Services Exclusions section. Service Area. Service Area references throughout the EOC have been modified. We have removed language indicating that covered Services must be provided in the Service Area. Service Area is a condition of eligibility. We provide covered Services using Participating Providers in Traditional, Deductible, and High Deductible Health Plans. We provide covered Services using Select Providers, PPO Providers, and in some instances Non- Participating Providers in Added Choice plans. 7

8 Skilled Nursing. The Skilled Nursing Services section of the EOC has been modified to show that habilitative services are covered in this setting. When You Can Enroll and When Coverage Begins. The When You Can Enroll and When Coverage Begins section has been modified. The Special Enrollment language is now more generalized in response to the federal Market Stabilization Rule. The section now states that qualifying events and special enrollment rights are administered under applicable state and federal law. Administrative changes or clarifications Receiving Care in Another Kaiser Foundation Health Plan Service Area. This section in the EOC has been modified for clarity. Group definition. We have modified the definition of Group to clarify that the number of employees is determined using the prior calendar year per ORS 743b.005(25). Medically Necessary. We have modified the definition of Medically Necessary to a more industrystandard definition and to provide more information about the process we use to determine if a service is Medically Necessary. Nondiscrimination. The Nondiscrimination section of the EOC has been modified to specify that we do not discriminate on the basis of actual or perceived gender in accordance with the Oregon (DFR) Bulletin to insurers. Covered Dental Services. The Covered Dental Services section clarifies that Covered Services provided by a dental hygienist under the supervision of a licensed dentist are covered. ADDITIONAL CHANGES AND CLARIFICATIONS THAT APPLY TO ADDED CHOICE MEDICAL PLANS ONLY Benefit changes Virtual Care Services. The Virtual Care Services section has been modified to include coverage under Tier 3. Services are covered at the Tier 3 Deductible, Copayment, or Coinsurance that would apply if the Service had been provided in person. Administrative changes or clarifications Outpatient Durable Medical Equipment. The Tier 1 section under the Outpatient Durable Medical Equipment (DME) section has been modified for clarity and consistency across product lines regarding decisions to repair, adjust, or replace the DME. Out-of-Pocket Maximums. The Tier 1 and Tier 2 Out-of-Pocket Maximums section has been modified to list all benefit riders that do not apply to the Out-of-Pocket Maximum for clarity. 8

9 2018 MEDICAL PLAN CHANGES PLAN NAME KP OR GOLD 0/30 KP OR GOLD 0/30 OUT OF POCKET INDIVIDUAL/FAMILY $5,000/$10,000 $5,250/$10,500 EMERGENCY $200 $300 GENERIC DRUGS $10 $15 BRAND DRUGS $20 $30 PLAN NAME KP OR SILVER 0/50 (discontinued) KP OR GOLD 0/30 OUT OF POCKET INDIVIDUAL/FAMILY $6,850/$13,700 $5,250/$10,500 COINSURANCE 35% PRIMARY CARE OFFICE VISIT $50 $30 SPECIALTY OFFICE VISIT $60 $40 X-RAY $60 $30 LAB $50 $30 OUTPATIENT SURGERY 35% MENTAL HEALTH OUTPATIENT $50 $30 INPATIENT HOSPITAL $500 copay per day, up to $2,500 per admission EMERGENCY $300 URGENT CARE $70 $50 GENERIC DRUGS $20 $15 BRAND DRUGS $40 $30 NON-PREFERRED BRAND DRUGS $60 DOCTOR-REFERRED ALTERNATIVE CARE $60 $40 AMBULANCE $200 DURABLE MEDICAL EQUIPMENT 35% THERAPIES $60 $40 SKILLED NURSING $500 copay per day, up to $2,500 per admission ADULT HEARING AIDS 35% PEDIATRIC HEARING AIDS 35% 9

10 PLAN NAME KP OR GOLD 500/20 KP OR GOLD 500/20 OUT OF POCKET INDIVIDUAL/FAMILY $5,350/$10,700 $5,850/$11,700 GENERIC DRUGS $10 $15 BRAND DRUGS $20 $30 PLAN NAME KP OR GOLD 1000/20 KP OR GOLD 1000/20 OUT OF POCKET INDIVIDUAL/FAMILY $5,000/$10,000 $6,000/$12,000 PLAN NAME KP OR SILVER 1500/35 (discontinued) KP OR SILVER 2000/40 OUT OF POCKET INDIVIDUAL/FAMILY $7,150/$14,300 $7,350/$14,700 PRIMARY CARE OFFICE VISIT $35 $40 MENTAL HEALTH OUTPATIENT $35 $40 GENERIC DRUGS $20 $30 BRAND DRUGS $40 $50 10

11 PLAN NAME KP OREGON STANDARD SILVER PLAN KP OREGON STANDARD SILVER PLAN OUT OF POCKET INDIVIDUAL/FAMILY $6,850/$13,700 $7,350/$14,700 PRIMARY CARE OFFICE VISIT $35 $40 SPECIALTY OFFICE VISIT $70 $80 MENTAL HEALTH OUTPATIENT $35 $40 BRAND DRUGS $50 $60 THERAPIES $35 $40 PLAN NAME KP OR SILVER 3500/40 KP OR SILVER 3500/40 OUT OF POCKET INDIVIDUAL/FAMILY $6,850/$13,700 $7,350/$14,700 GENERIC DRUGS $20 $30 BRAND DRUGS $40 $50 PLAN NAME KP OR BRONZE 6600/35 KP OR BRONZE 6600/40 BRAND DRUGS NON-PREFERRED BRAND DRUGS SPECIALTY DRUGS INDIVIDUAL DRUG DEDUCTIBLE N/A $400 drug drug drug 11

12 PLAN NAME KP OR SILVER 2600/ HSA KP OR SILVER 2700/ HSA DEDUCTIBLE $2,600/$5,200 $2,700/$5,400 OUT OF POCKET INDIVIDUAL/FAMILY $5,200/$10,400 $5,400/$10,800 PLAN NAME KP OREGON STANDARD BRONZE PLAN KP OREGON STANDARD BRONZE HSA PLAN OUT OF POCKET INDIVIDUAL/FAMILY $7,150/$14,300 $6,550/$13,100 PRIMARY CARE OFFICE VISIT $7,150/$14,300 $6,550/$13,100 SPECIALTY OFFICE VISIT $70 0% MENTAL HEALTH OUTPATIENT $115 0% BRAND DRUGS $70 0% THERAPIES $100 0% GENERIC DRUGS $35 0% PLAN NAME KP OR PLATINUM 250/10 3T POS KP OR PLATINUM 250/10 3T POS Tier PRENATAL CARE $0 $25 35% $0 $0 35% PREVENTIVE CARE $0 $25 35% $0 $0 35% 12

13 PLAN NAME KP OR GOLD 600/35 3T POS KP OR GOLD 600/35 3T POS Tier OUT OF POCKET INDIVIDUAL/FAMILY $2,000/ $4,000 $6,000/ $12,000 $8,000/ $16,000 $2,500/ $5,000 $6,000/ $12,000 $8,000/ $16,000 PRENATAL CARE $0 $60 PREVENTIVE CARE $0 $60 $0 $0 $0 $0 PLAN NAME KP OR GOLD 600/35 3T POS OOA KP OR GOLD 600/35 3T POS OOA Tier OUT OF POCKET INDIVIDUAL/ FAMILY $2,000/ $4,000 $3,200/ $6,400 $8,000/ $16,000 $2,500/ $5,000 $4,500/ $9,000 $8,000/ $16,000 PLAN NAME KP OR GOLD 1000/35 3T POS KP OR GOLD 1000/35 3T POS Tier PRENATAL CARE PREVENTIVE CARE $0 $60 $0 $60 $0 $0 $0 $0 13

14 PLAN NAME KP OR GOLD 1000/35 3T POS OOA 2018 KP OR GOLD 1000/35 3T POS OOA Tier OUT OF POCKET INDIVIDUAL/FAMILY $3,000/ $6,000 $3,000/ $6,000 $9,000/ $18,000 $3,500/ $7,000 $3,500/ $7,000 $9,000/ $18,000 COINSURANCE CT, MRI, AND PET SCANS $200 $200 $300 $300 OUTPATIENT SURGERY INPATIENT HOSPITAL MATERNITY DELIVERY EMERGENCY ROOM See Tier 1 See Tier 1 See Tier 1 See Tier 1 DURABLE MEDICAL EQUIPMENT SKILLED NURSING ADULT HEARING AIDS PEDIATRIC HEARING AIDS 14

15 PLAN NAME KP OR SILVER 2000/40 3T POS KP OR SILVER 2500/40 3T POS Tier DEDUCTIBLE INDIVIDUAL/FAMILY $2,000/ $4,000 $4,000/ $8,000 $6,000/ $12,000 $2,500/ $5,000 $4,500/ $9,000 $6,500/ $13,000 OUT OF POCKET INDIVIDUAL/FAMILY X-RAY LAB $5,750/ $11,500 PRENATAL CARE $0 $60 $7,150/ $14,300 $12,000/ $24,000 $6,500/ $13,000 $40 $40 $0 $0 $7,350/ $14,700 $12,500/ $25,000 GENERIC DRUGS $20 Not covered $30 $30 Not covered $30 PREVENTIVE CARE $0 $60 $0 $0 15

16 PLAN NAME KP OR SILVER 2000/40 3T POS OOA KP OR SILVER 2500/40 3T POS OOA Tier DEDUCTIBLE INDIVIDUAL/FAMILY OUT OF POCKET INDIVIDUAL/FAMILY $2,000/ $4,000 $5,750/ $11,500 $2,000/ $4,000 $7,150/ $14,300 $6,000/ $12,000 $12,000/ $24,000 $2,500/ $5,000 $6,500/ $13,000 $2,500/ $5,000 $7,150/ $14,300 $5,000/ $10,000 $12,000/ $24,000 X-RAY LAB CT, MRI, AND PET SCANS OUTPATIENT SURGERY INPATIENT HOSPITAL MATERNITY EMERGENCY ROOM DURABLE MEDICAL EQUIPMENT ADMINISTERED MEDS SKILLED NURSING FACILITY ADULT HEARING AIDS PEDIATRIC HEARING AIDS See Tier 1 See Tier 1 See Tier 1 See Tier 1 16

17 2018 DENTAL PLAN CHANGES AND REMINDERS The Affordable Care Act requires health insurance marketplace certified pediatric dental coverage for all subscribers and dependents regardless of age. For pediatric dental plans, the annual out-of-pocket maximum for in-network services is $350 for an individual under 19 and $700 for a family (of 2 or more pediatric members enrolled). Groups also have the option of adding adult dental coverage. Please make your selection from the options listed above. CHANGES AND CLARIFICATIONS THAT APPLY TO DENTAL PLANS Benefit changes Schedule of Covered Pediatric Dental Procedures. The Schedule of Covered Pediatric Dental Procedures has been modified to comply with Oregon and Washington benchmark requirements for pediatric dental coverage. Benefit clarifications All references of plastic restorations have been updated to composite for accuracy. In the Limitations section, the time frame for the repair or replacement of interim fixed and removable prosthetic devices due to normal wear and tear has been clarified as once every 12 months. Administrative changes or clarifications Nondiscrimination. The Nondiscrimination section of the EOC has been modified to specify that we do not discriminate on the basis of actual or perceived gender in accordance with the Oregon (DFR) Bulletin to insurers. 17

18 OREGON HEALTH INSURANCE MARKETPLACE CERTIFIED PEDIATRIC PLANS AND ADULT DENTAL PLANS PPO pediatric plans KP OR Choice 80 Pediatric Dental Plan KP OR Choice 100 Pediatric Dental Plan KP OR Choice Ortho Pediatric Dental Plan Traditional adult-only plans KP OR Adult Traditional 80 $1,000 Max KP OR Adult Traditional 100 $100 Ded/$1500 Max KP OR Adult Traditional 80 $50 Ded/$1,000 Max KP OR Adult Traditional 100 $1,500 Max + Ortho KP OR Adult Traditional 80 $100 Ded/$1,000 Max KP OR Adult Traditional 100 $2,000 Max KP OR Adult Traditional 80 $1,000 Max + Ortho KP OR Adult Traditional 100 $50 Ded/$2,000 Max KP OR Adult Traditional 100 $1,000 Max KP OR Adult Traditional 100 $100 Ded/$2,000 Max KP OR Adult Traditional 100 $50 Ded/$1,000 Max KP OR Adult Traditional 100 $2,000 Max + Ortho KP OR Adult Traditional 100 $100 Ded/$1,000 Max KP OR Adult Traditional 100 $50 Ded/$2,500 Max KP OR Adult Traditional 100 $1,000 Max + Ortho KP OR Adult Traditional 100 $100 Ded/$2,500 Max KP OR Adult Traditional 100 $1,500 Max KP OR Adult Traditional 100 $2,500 Max + Ortho KP OR Adult Traditional 100 $50 Ded/$1,500 Max PPO adult-only plans KP OR Adult Choice 80 $50 Ded/$1,000 Max KP OR Adult Choice 80 $100 Ded/$1,000 Max KP OR Adult Choice 80 $1,000 Max + Ortho KP OR Adult Choice 100 $50 Ded/$1,000 Max KP OR Adult Choice 100 $100 Ded/$1,000 Max KP OR Adult Choice 100 $1,000 Max + Ortho KP OR Adult Choice 100 $50 Ded/$1,500 Max KP OR Adult Choice 100 $100 Ded/$1,500 Max KP OR Adult Choice 100 $1,500 Max + Ortho KP OR Adult Choice 100 $50 Ded/$2,000 Max KP OR Adult Choice 100 $100 Ded/$2,000 Max KP OR Adult Choice 100 $2,000 Max + Ortho KP OR Adult Choice 100 $50 Ded/$2,500 Max KP OR Adult Choice 100 $100 Ded/$2,500 Max KP OR Adult Choice 100 $2,500 Max + Ortho Dental EOC form numbers: EOSGPEDDNTPPO0118 EOSGADULTDNTDED0118 EOSGPEDDNTDEDPPO0118 EOSGADULTDNTDEDPPO0118 EOSGADULTDNT0118 CHANGES AND CLARIFICATIONS THAT APPLY TO THE SENIOR ADVANTAGE PLAN Outpatient Durable Medical Equipment. We have added coverage for wigs limited to 1 synthetic wig per year following chemotherapy or radiation therapy to the Outpatient Durable Medical Equipment section. 18

19 NOTES 19

20 account.kp.org _NW-OR_11/ Kaiser Foundation Health Plan of the Northwest