2011 small business California. Plan highlights. Effective January to June 2011

Transcription

1 2011 small busiess Califoria Pla highlights Effective Jauary to Jue Small Busiess

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3 Cotets Copaymet plas Predictable out-of-pocket costs ad o aual deductible to meet for medical services Deductible HMO plas Lower mothly premiums ad doctor visits are ot subject to the deductible HSA-qualified deductible HMO plas Lower mothly premiums, plus optioal employee-owed savigs accouts provide a iovative way to pay for qualified medical expeses Deductible HMO plas with health reimbursemet arragemet (HRA) A IRS-regulated, employer-sposored program that allows your employees to receive tax-free dollars from you to pay for qualified medical expeses 1 $35 POS Pla A poit-of-service pla that gives employees access to Kaiser Permaete medical care with the added flexibility of choosig physicias ad services from a exteral provider etwork or ay licesed provider $40/$2,500 PPO Isurace Pla with HSA Optio Our HSA-optio PPO offers the flexibility of a PPO alog with lower mothly premiums ad optioal employee-owed savigs accouts. $40/$1,000 PPO Isurace Pla Choose a physicia from a cotracted etwork or ay licesed oparticipatig provider. Detal plas A variety of detal pla optios, icludig Delta Detal Premier, Delta Detal PPO, ad DeltaCare HMO plas Chiropractic beefits Chiropractic ad Chiropractic/Acupucture optios provide members up to 20 visits aually for a copaymet of oly $15 per visit. The copaymet plas, HSA-qualified deductible HMO plas, deductible HMO plas, deductible HMO plas with HRA, ad the i-etwork portio of the poit-of-service (POS) pla are uderwritte by Kaiser Foudatio Health Pla, Ic. (KFHP). Kaiser Permaete Isurace Compay (KPIC), a subsidiary of KFHP, uderwrites the PPO pla ad the out-of-etwork portio of the POS pla as well as the Delta Detal of Califoria detal plas. The chiropractic beefit is admiistered by America Specialty Health Plas of Califoria, Ic. The chiropractic/acupucture beefit is admiistered by Private Healthcare Systems. 1 Tax refereces relate to federal icome tax oly. Cosult with your fiacial or tax adviser for more iformatio.

4 KAISER PERMANENTE Copaymet plas Pla Highlights Features $50 Pla Member Pays Most Popular Copaymet pla $30 Pla Member Pays $20 Pla Member Pays $15 Pla Member Pays Effective 1/1/11 6/1/11 $5 Pla Member Pays Caledar-Year Deductible Pharmacy Caledar-Year Deductible $250 for brad prescriptio $250 for brad prescriptio N/A N/A N/A Aual Out-of-Pocket Maximum 1 Self-oly erollmet/family erollmet $3,500/$7,000 $3,000/$6,000 $2,500/$5,000 $2,500/$5,000 $1,500/$3,000 I the Medical Office Office visits Prevetive exams Materity/Preatal care 2 Well-child prevetive care visits 3 Vaccies (immuizatios) Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 4 Geeric 5 Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 100 days per beefit period) Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) Optical (eyewear) Visio exam Home health care (up to 100 two-hour visits per caledar year) Hospice care $50 $5 $50 $50 $250 per procedure $150 $300 (up to a 100-day supply) $35 (after pharmacy deductible) $500 per day $50 idividual $25 group $500 per day $50 idividual $500 per day 6 7 $30 $5 $30 $50 $200 per procedure 0 $75 (up to a 100-day supply) $35 (after pharmacy deductible) $400 per day $30 idividual $15 group $400 per day $30 idividual $400 per day 6 7 $20 $5 $20 $50 $150 per procedure 0 $75 (up to a 30-day supply) $30 5 $300 per day $20 idividual group $300 per day $20 idividual $300 per day 20% ($2,000 maximum) 7 $15 $5 $15 $50 0 per procedure 0 $75 (up to a 30-day supply) $25 5 $200 per day $15 idividual $7 group $200 per day $15 idividual $200 per day 20% ($2,000 maximum) $150 allowace 8 $5 $5 $50 $5 per procedure 0 $75 (up to a 100-day supply) $5 $15 5 $5 idividual $2 group $5 idividual 20% ($2,000 maximum) $150 allowace 8 Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage (EOC) or busiesset.kp.org. 1 The aual out-of-pocket maximum is the limit to the total amout that a idividual or family must pay for certai services i a caledar year (as discussed i the Evidece of Coverage). 2 Scheduled preatal visits ad the first postpartum visit 3 Well-child visits through age 23 moths 4 Prescriptio drugs are covered i accord with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 5 This service is ot subject to a deductible. 6 Please refer to the Evidece of Coverage for more iformatio; most DME is ot covered. 7 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotioal, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 8 Allowace toward the cost of eyeglass leses, frames, ad cotact leses fittig ad dispesig every 24 moths 2

5 KAISER PERMANENTE DEDUCTIBLE HMO plas Pla Highlights Features $40/$2,000 PLAN Member Pays Most Popular Deductible pla $30/$1,500 PLAN Member Pays Effective 1/1/11 6/1/11 $30/$1,000 PLAN Member Pays Caledar-Year Deductible 1 Idividual/Family $2,000/$4,000 $1,500/$3,000 $1,000/$2,000 Pharmacy Caledar-Year Deductible N/A N/A N/A Aual Out-of-Pocket Maximum 1,2 Idividual/Family $4,500/$9,000 $3,500/$7,000 $3,500/$7,000 I the Medical Office Office visits 3 Prevetive exams 3 Materity/Preatal care 3,4 Well-child prevetive care visits 3,5 Vaccies (immuizatios) 3 Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 3,6 Geeric Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 60 days per beefit period) Metal Health Services I the medical office 3 I the hospital Chemical Depedecy Services I the medical office 3 I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) 7 Optical (eyewear) 8 Visio exam 3 Home health care 3 (up to 100 two-hour visits per caledar year) Hospice care 3 $40 $5 $40 $50 0 (up to a 30-day supply) $35 per admissio per admissio $40 (for idividual therapy) $20 (for group therapy) per admissio $40 (for idividual therapy) per admissio $30 $5 $30 $50 $250 0 $75 (up to a 30-day supply) $30 $500 per day $50 per day $30 (for idividual therapy) $15 (for group therapy) $500 per day $30 (for idividual therapy) $500 per day $30 $5 $30 $50 $250 0 $75 (up to a 30-day supply) $30 $500 per day $50 per day $30 (for idividual therapy) $15 (for group therapy) $500 per day $30 (for idividual therapy) $500 per day Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage (EOC) or busiesset.kp.org. 1 This pla carries a embedded deductible. Each family member becomes eligible for copaymets or coisurace after meetig the idividual deductible, or whe the family deductible is satisfied. A family member ca meet the idividual aual out-of-pocket maximum before the family out-of-pocket maximum is satisfied. 2 The aual out-of-pocket maximum is the limit to the total amout that a idividual or family must pay for certai services i a caledar year (as discussed i the Evidece of Coverage). 3 This service is ot subject to a deductible. 4 Scheduled preatal visits ad the first postpartum visit 5 Well-child visits through age 23 moths 6 Prescriptio drugs are covered i accord with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 7 Please refer to the Evidece of Coverage for more iformatio; most DME is ot covered. 8 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotioal, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 3

6 4 KAISER PERMANENTE HSA-Qualified Deductible HMO plas Pla Highlights Features $30/$3,000 Pla w/hsa Member Pays Most Popular DEDUCTIBLE pla W/HSA /$2,700 Pla w/hsa Member Pays Caledar-Year Deductible Idividual/Family $3,000/$6,000 1 $2,700/$5,450 1 $2,000/$4,000 2 Pharmacy Caledar-Year Deductible N/A N/A N/A Aual Out-of-Pocket Maximum 3 Idividual/Family $5,950/$11,900 1 $4,500/$9,000 1 $3,500/$7,000 2 I the Medical Office Office visits Prevetive exams 4 Materity/Preatal care 4,5 Well-child prevetive care visits 4,6 Vaccies (immuizatios) 4 Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 7 Geeric Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 100 days per beefit period) Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) 8 Optical (eyewear) 9 Visio exam Home health care (up to 100 two-hour visits per caledar year) Hospice care $30 $5 $30 $50 0 (up to a 30-day supply) $30 per admissio per admissio $30 (after deductible for idividual therapy) $15 (after deductible for group therapy) per admissio $30 (after deductible for idividual therapy) per admissio $30 $50 $ (up to a 30-day supply) $30 $450 per day per admissio (after deductible for idividual therapy) (after deductible for group therapy) $450 per day (after deductible for idividual therapy) $450 per day Effective 1/1/11 6/1/11 /$2,000 PLAN w/hsa Member Pays $50 $ (up to a 30-day supply) $30 $300 per day per admissio (after deductible for idividual therapy) (after deductible for group therapy) $300 per day (after deductible for idividual therapy) $300 per day Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage (EOC) or busiesset.kp.org. 1 This pla carries a embedded deductible. Each family member becomes eligible for copaymets or coisurace after meetig the idividual deductible, or whe the family deductible is satisfied. A family member ca meet the idividual aual out-of-pocket maximum before the family out-of-pocket maximum is satisfied. 2 This pla has a aggregate deductible. For family erollmet, there is oly oe deductible for the whole family. Oce it s met, either idividually or collectively, the family pays oly copaymets ad coisurace for the remaider of the caledar year, or util the family out-of-pocket maximum is satisfied. 3 The aual out-of-pocket maximum is the limit to the total amout that a idividual or family must pay for certai services i a caledar year (as discussed i the Evidece of Coverage). 4 This service is ot subject to a deductible. 5 Scheduled preatal visits 6 Well-child visits through age 23 moths 7 Prescriptio drugs are covered i accord with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 8 Please refer to the Evidece of Coverage for more iformatio; most DME is ot covered. 9 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotioal, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios.

7 KAISER PERMANENTE Deductible HMO plas with HRA Pla Highlights Effective 1/1/11 6/1/11 Features $30/$2,500 PLAN WITH HRA Member Pays $30/$1,500 PLAN WITH HRA Member Pays Caledar-Year Deductible 1 Idividual/Family $2,500/$5,000 $1,500/$3,000 Pharmacy Caledar-Year Deductible N/A N/A Aual Out-of-Pocket Maximum 1,2 Idividual/Family $5,000/,000 $3,500/$7,000 I the Medical Office Office visits Prevetive exams 3 Materity/Preatal care 3,4 Well-child prevetive care visits 3,5 Vaccies (immuizatios) 3 Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 3,6 Geeric Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) 7 Optical (eyewear) 8 Visio exam 3 Home health care 3 (up to 100 two-hour visits per caledar year) Hospice care 3 $30 $30 $50 20% 20% $150 (up to a 30-day supply) $30 20% per admissio 20% per day (up to 100 days per beefit period) $30 (after deductible for idividual therapy) $15 (after deductible for group therapy) 20% per admissio $30 (after deductible for idividual therapy) 20% per admissio $30 $30 $50 20% 20% $150 (up to a 30-day supply) $30 20% per admissio 20% per day (up to 100 days per beefit period) $30 (after deductible for idividual therapy) $15 (after deductible for group therapy) 20% per admissio $30 (after deductible for idividual therapy) 20% per admissio Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage (EOC) or busiesset.kp.org. Employer must fud at least 25 percet of the subscriber s deductible for the $30/$1,500 Deductible HMO Pla with HRA ad at least 40 percet of the subscriber s deductible for the $30/$2,500 Deductible HMO Pla with HRA. With a HRA, you are required to work with your ow chose third-party admiistrator. 1 This pla carries a embedded deductible. Each family member becomes eligible for copaymets or coisurace after meetig the idividual deductible, or whe the family deductible is satisfied. A family member ca meet the idividual aual out-of-pocket maximum before the family out-of-pocket maximum is satisfied. 2 The aual out-of-pocket maximum is the limit to the total amout that a idividual or family must pay for certai services i a caledar year (as discussed i the Evidece of Coverage). 3 This service is ot subject to a deductible. 4 Scheduled preatal visits ad the first postpartum visit 5 Well-child visits through age 23 moths 6 Prescriptio drugs are covered i accord with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 7 Please refer to the Evidece of Coverage for more iformatio; most DME is ot covered. 8 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotioal, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 5

8 KAISER PERMANENTE $35 POS PLAN Pla Highlights Kaiser Permaete Pla providers (HMO) (i-etwork) PHCS providers (PPO)* Effective 1/1/11 6/1/11 Noparticipatig providers (out-of-etwork)* Features Member Pays Member Pays Member Pays Caledar-Year Deductible 1 Idividual/Family $500/$1,500 Pharmacy Caledar-Year Deductible N/A N/A Aual Out-of-Pocket Maximum 2,3 Idividual/Family $3,000/$6,000 $3,000/$9,000 4 $6,000/$18,000 4 I the Medical Office Office visits Routie adult physical exams Adult prevetive screeig exam Materity/Preatal care 6 Well-child prevetive care visits Vaccies (immuizatios) Allergy ijectios Ifertility services 9 Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace $35 7 $5 $35 $ $75 $45 $45 $45 $25 $25 8 $25 $ Emergecy Departmet visits ad ambulace for emergecy medical coditios are covered as a HMO beefit for services received at ay provider. Prescriptios 12 (up to a 100-day supply) Geeric Brad-ame Noformulary Obtaied at Kaiser Permaete Pla pharmacies (icludig affiliated pharmacies) $35 $50 Obtaied at participatig MedImpact pharmacies 13 $15 $40 $60 Obtaied at o Kaiser Permaete ad o MedImpact pharmacies Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care 14 $200 per day 15 Metal Health Services 16 I the medical office I the hospital $35 idividual therapy $17 group therapy $200 per day $45 per idividual therapy visit $45 group therapy per idividual therapy visit group therapy Chemical Depedecy Services I the medical office I the hospital $35 idividual therapy $5 group therapy $200 per day $45 per idividual therapy visit $45 group therapy per idividual therapy visit group therapy Other Certai durable medical equipmet (DME) 17 Prosthetics, orthotics, ad special footwear Optical (eyewear) Visio exam Home health care Hospice care $40 19 (up to 100 two-hour visits per caledar year) 18 20% % Maximum beefit while isured Ulimited $2 millio 5 For your group to be eligible for the $35 POS Pla, the $40/$1,000 PPO Pla, or the $40/$2,500 PPO Pla with HSA Optio, you must have Kaiser Permaete as your sole carrier, ad the pla must be offered with at least oe copaymet or deductible HMO pla as part of a multiple pla offerig. If you iclude a PPO or POS pla i your multiple pla offerig, at least 70 percet of all employees erolled i the Health Pla must be erolled i a copaymet or deductible HMO pla, ad combied erollmet i KPIC medical plas must ot exceed 30 percet. See foototes ad other importat iformatio o pages 7 ad 12. 6

9 NOTES for the Kaiser permaete $35 POS Pla Kaiser Permaete plas do ot iclude a pre-existig coditio clause. * Based o maximum allowable charge for covered services Paymets are based upo the maximum allowable charge for covered services. Maximum allowable charge meas the lesser of: the usual, customary, ad reasoable charges; or the egotiated rate; or the actual billed charges. The maximum allowable charge may be less tha the amout actually billed by the provider. Covered persos may be resposible for paymet of ay amouts i excess of the maximum allowable charge for a covered service. 1 Deductible amouts are combied for services provided by PHCS etwork ad oparticipatig providers. Deductibles do ot cout toward satisfyig the out-of-pocket maximum. This pla carries a embedded deductible. Each family member becomes eligible for beefits after meetig the idividual deductible, or whe the family deductible is satisfied. 2 The aual out-of-pocket maximum (OOPM) is the limit to the total amout that a idividual (self-oly) or family must pay for certai services i a caledar year (as discussed i the Evidece of Coverage ad the Certificate of Isurace). A family member ca meet the idividual aual out-of-pocket maximum before the family out-of-pocket maximum is satisfied. 3 Covered charges icurred to satisfy the out-of-pocket maximum at the PHCS etwork level will ot be applicable toward satisfactio of the out-ofpocket maximum at the oparticipatig providers level. Likewise, covered charges applied to satisfy the out-of-pocket maximum at the oparticipatig providers level will ot be applicable toward satisfactio of the out-of-pocket maximum at the PHCS etwork level. Covered charges icurred to satisfy the out-of-pocket maximum at the Kaiser Permaete i-etwork providers level will ot be applicable toward satisfactio of the out-of-pocket maximum at the PHCS etwork or oparticipatig providers level. Covered charges at the PHCS etwork ad oparticipatig providers level will ot be applicable toward the satisfactio of the out-of-pocket maximum at the Kaiser Permaete i-etwork providers level. 4 The family out-of-pocket maximum equals three times the idividual out-of-pocket maximum for family cotracts of three or more members. Family cotracts with two members will require each member to satisfy the idividual out-of-pocket maximum. 5 Maximum beefit while isured is $2 millio combied for services provided by PHCS etwork ad oparticipatig providers. 6 Scheduled preatal visits ad the first postpartum visit. 7 Well-child care is covered by Kaiser Permaete Pla providers (HMO) through age 23 moths. 8 Well-child care (ages 0 to 18) is exempt from deductibles from PHCS etwork providers ad icludes immuizatios. 9 I accordace with Califoria law, health care plas ad isurers are required to offer cotract holders ad policyholders the optio to purchase coverage of ifertility treatmet (excludig i vitro fertilizatio). For details regardig this optioal coverage, icludig how you may elect this coverage ad the amout of additioal rates, please cotact your broker or the Accout Maagemet Team at All outpatiet therapies are limited to 60 days per caledar year for services from PHCS etwork ad oparticipatig providers combied. 11 Kaiser Permaete Isurace Compay (KPIC) pays a maximum of $400 per procedure for outpatiet surgery services from oparticipatig providers. 12 A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. Noformulary prescriptios that are ot covered as a HMO beefit are uderwritte by Kaiser Permaete Isurace Compay (KPIC), a subsidiary of Kaiser Foudatio Health Pla, Ic. 13 Participatig MedImpact pharmacy copaymets ad deductibles are ot subject to, or do they cotribute toward satisfactio of, the caledar-year deductible or the OOPM. Select prescriptio medicatios are excluded from coverage. Please cosult your participatig pharmacy directory for a curret list of participatig pharmacies. 14 Care i a skilled ursig facility is limited to 100 days per beefit period. 15 Kaiser Permaete Isurace Compay pays a maximum of $600 per day combied for all hospital care received from oparticipatig providers, excludig physicia, surgeo, ad surgical services. 16 Visit or day limits do ot apply to covered services associated with metal health or alcohol/chemical depedecy as described i the Evidece of Coverage ad the KPIC Certificate of Isurace. 17 Please refer to the Evidece of Coverage ad the Certificate of Isurace for more iformatio. DME is limited to a combied maximum of $2,000 per caledar year for services provided by PHCS etwork ad oparticipatig providers, excludig diabetic testig supplies ad equipmet. 18 Durable medical equipmet beefit is limited to $2,000 maximum per caledar year for services from PHCS etwork ad oparticipatig providers combied, excludig diabetic testig supplies ad equipmet. 19 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotioal, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 20 Home health care is limited to a maximum of 100 visits per caledar year combied for services provided by PHCS etwork ad oparticipatig providers. Deductible amout is limited to a maximum of $50 per caledar year. 21 Hospice care is limited to a 180-day lifetime beefit maximum for services from PHCS etwork ad oparticipatig providers combied. HMO exclusios ad limitatios Exclusios ad limitatios are listed i the Evidece of Coverage cotaied i the Group Agreemet. 7

10 KAISER PERMANENTE $40/$2,500 PPO INSURANCE PLAN WITH HSA OPTIO Pla Highlights 8 PHCS etwork (PPO)* Noparticipatig providers (out-of-etwork)* Features Member Pays Member Pays Caledar-Year Deductible 1 Idividual/Family $2,500/$5,000 $3,500/$7,000 Aual Out-of-Pocket Maximum 2 Idividual/Family 5,000/,000,000/$20,000 hospital CAre Room, board, ad critical care uits Imagig, icludig X-rays ad lab tests Trasplats Physicia, surgeo, ad surgical services Nursig care, aesthesia, ad ipatiet prescribed drugs outpatiet care Physicia office visits Routie adult physical exams Adult prevetive screeig exam Well-child prevetive care visits (through age 18) 7 Pediatric visits Outpatiet surgery Allergy testig visits Allergy ijectio visits Gyecological visits Materity/Scheduled preatal care ad first postpartum visit Diagostic imagig, icludig X-rays Diagostic lab tests Eye exams for eyeglass prescriptios Hearig screeigs Occupatioal, physical, respiratory, ad speech therapy visits 9 Health educatio emergecy services Emergecy Departmet visits Emergecy ambulace service Medically ecessary oemergecy ambulace service 10 Noemergecy urget care Prescriptios 11 Geeric drugs Brad-ame drugs Self-admiistered ijectable medicatios 13 Mail-order geeric drugs Mail-order brad-ame drugs metal health care Ipatiet hospitalizatio (Icludig severe metal illess ad serious emotioal disturbaces of a child) Outpatiet visits (Icludig severe metal illess ad serious emotioal disturbaces of a child) Alcohol ad chemical depedecy Ipatiet hospitalizatio Outpatiet visits Additioal beefits Care i a skilled ursig facility (60-day combied limit per caledar year) Home health care (100-day combied limit per caledar year) Hospice care (180-day combied lifetime limit) Ifertility services 14 Durable medical equipmet (DME) 15 Prosthetics, orthotics, ad special footwear Diabetic equipmet ad supplies 16 $40 copay 5,6 $40 copay $40 copay 0 copay, the (copay waived if admitted) MedImpact pharmacy 12 $15 copay (maximum 30-day supply) $35 copay (maximum 30-day supply) $30 copay (maximum 100-day supply) $70 copay (maximum 100-day supply) $40 copay $40 copay 20% copay, the (copay waived if admitted) No MedImpact pharmacy % Maximum beefit while isured 3 Ulimited $5 milllio For your group to be eligible for the $35 POS Pla, the $40/$1,000 PPO Pla, or the $40/$2,500 PPO Pla with HSA Optio, you must have Kaiser Permaete as your sole carrier, ad the pla must be offered with at least oe copaymet or deductible HMO pla as part of a multiple pla offerig. If you iclude a PPO or POS pla i your multiple pla offerig, at least 70 percet of all employees erolled i the Health Pla must be erolled i a copaymet or deductible HMO pla, ad combied erollmet i KPIC medical plas must ot exceed 30 percet. See foototes ad other importat iformatio o pages 9 ad 12. Effective 1/1/11 6/1/11

11 otes for the Kaiser permaete $40/$2,500 PPO INSURANCE PLAN WITH HSA OPTION Kaiser Permaete plas do ot iclude a pre-existig coditio clause. * Based o maximum allowable charge for covered services Paymets are based upo the maximum allowable charge for covered services. Maximum allowable charge meas the lesser of: the usual, customary, ad reasoable charges; or the egotiated rate; or the actual billed charges. The maximum allowable charge may be less tha the amout actually billed by the provider. Covered persos may be resposible for paymet of ay amouts i excess of the maximum allowable charge for a covered service. 1 Caledar-year deductible amouts are separate for services provided by PHCS etwork ad oparticipatig providers. Covered charges applied towards the satisfactio of the caledar-year deductible may also be applied towards the satisfactio of the out-of-pocket maximum. 2 Out-of-pocket maximums are separate for services provided by PHCS etwork ad oparticipatig providers. 3 Maximum beefit amout while isured applies to charges from oparticipatig providers oly. 4 Kaiser Permaete Isurace Compay (KPIC) pays a maximum of $600 per day combied for all hospital care received from oparticipatig providers, excludig physicia, surgeo, ad surgical services. 5 This service is ot subject to a deductible. 6 Routie adult physical exams are limited to oe exam every 12 moths. Prevetive lab tests, X-ray, ad immuizatios are covered as part of the prevetive exam. 7 Well-child prevetive care icludes immuizatios. 8 Kaiser Permaete Isurace Compay pays a maximum of $400 per procedure for outpatiet surgery services from oparticipatig providers. 9 All outpatiet therapies are limited to 60 visits per caledar year combied for both PHCS etwork ad oparticipatig providers. 10 The PHCS etwork does ot cotract for ambulace service. Therefore, medically ecessary oemergecy ambulace service is payable at the oparticipatig providers level. Noemergecy ambulace coverage is limited to a maximum of $2,000 per caledar year for all services. 11 Member is resposible for payig the brad-ame copay plus the differece i cost betwee the geeric drug ad the brad-ame drug whe the patiet requests a brad-ame drug ad a geeric versio is available. 12 MedImpact pharmacy copaymets are subject to the satisfactio of the caledar-year deductible ad out-of-pocket maximum. Drugs prescribed for family plaig are subject to the caledar-year deductible. Select prescriptio drugs are excluded from coverage. 13 Self-admiistered ijectable medicatios are limited to a 30-day maximum supply ad are ot available uder the mail-order service. Prescriptios for isuli are covered at the brad-ame or geeric copaymet level. 14 Beefits payable for treatmet of ifertility are limited to $1,000 per lifetime combied for services provided by PHCS etwork or oparticipatig providers. I vitro fertilizatio is ot covered. Beefits payable for diagosis of ifertility will be covered o the same basis as ay other illess. 15 Certai durable medical equipmet ad supplies are limited to $2,000 maximum beefit per caledar year for services from oparticipatig providers, excludig diabetic testig supplies ad equipmet. 16 Diabetic equipmet ad supplies are limited to ifusio set ad syrige with eedle for exteral isuli pumps, testig strips, lacets, ski barrier, adhesive remover wipes, ad trasparet film. Coisurace amouts are based o actual billed charges ad are ot subject to the DME aual maximum limit of $2,000 per caledar year. Importat otice regardig the $40/$2,500 PPO Isurace Pla with HSA Optio This chart is a summary of the beefits for a federally qualified High Deductible Health Pla (HDHP) compatible with Health Savigs Accouts (HSAs) i accordace with the Medicare Prescriptio Drug, Improvemet ad Moderizatio Act of 2003, as the costituted or later ameded. Erollmet i a HDHP that is HSA-compatible is oly oe of the eligibility requiremets for establishig ad cotributig to a HSA. Please cosult with your employer about other eligibility requiremets for establishig a HSA-qualified pla. Please ote: If you have other health coverage, icludig coverage uder Medicare, i additio to the coverage uder this Group Policy, you may ot be eligible to establish or cotribute to a HSA uless both coverages qualify as High Deductible Health Plas. Kaiser Permaete Isurace Compay (KPIC) does ot provide tax advice. The Califoria Departmet of Isurace does NOT i ay way warrat that this pla meets the federal requiremets. Cosult with your fiacial or tax adviser for tax advice or more iformatio about your eligibility for a HSA. 9

12 KAISER PERMANENTE $40/$1,000 PPO isurace pla Pla Highlights Effective 1/1/11 6/1/11 PHCS etwork (PPO)* Noparticipatig providers (out-of-etwork)* Features Member Pays Member Pays Caledar-Year Deductible 1 Idividual/Family $1,000/$2,000 Aual Out-of-Pocket Maximum 1,2 Idividual/Family $5,000/,000,000/$20,000 hospital care Room, board, ad critical care uits Imagig, icludig X-rays ad lab tests Trasplats Physicia, surgeo, ad surgical services Nursig care, aesthesia, ad ipatiet prescribed drugs outpatiet care Physicia office visits Routie adult physical exams 7 Adult prevetive screeig exam Well-child prevetive care visits (through age 18) Pediatric visits Outpatiet surgery Allergy testig visits Allergy ijectio visits Gyecological visits Materity/Scheduled preatal care ad first postpartum visit Diagostic imagig, icludig X-rays Diagostic lab tests Eye exams for eyeglass prescriptios Hearig screeigs Occupatioal, physical, respiratory, ad speech therapy visits 10 Health educatio emergecy services Emergecy Departmet visits Emergecy ambulace service Medically ecessary oemergecy ambulace service 11 Prescriptios 12 Geeric drugs Brad-ame drugs (pharmacy ad mail order) Brad-ame drugs Self-admiistered ijectable medicatios 14 Mail-order geeric drugs Mail-order brad-ame drugs metal health care Ipatiet hospitalizatio (Icludig severe metal illess ad serious emotioal disturbaces of a child) Outpatiet visits (Icludig severe metal illess ad serious emotioal disturbaces of a child) Alcohol ad chemical depedecy Ipatiet hospitalizatio Outpatiet visits Additioal beefits Care i a skilled ursig facility (60-day combied limit per caledar year) Home health care (100-day combied limit per caledar year) 15 Hospice care (180-day combied lifetime limit) Ifertility services 16 Durable medical equipmet (DME) 17 Prosthetics, orthotics, ad special footwear Diabetic equipmet ad supplies $40 copay 5,6 $40 copay 5,6 $40 copay 5,6 0 copay, the (copay waived if admitted) MedImpact pharmacy 13 $15 copay 5 (maximum 30-day supply) $200 deductible 5 $35 copay 5 (maximum 30-day supply) 5 $30 copay 5 (maximum 100-day supply) $70 copay 5 (maximum 100-day supply) 5,6 $40 copay 5, copay, the (copay waived if admitted) No MedImpact pharmacy 4 $40 copay 5,6 4 20% Maximum beefit while isured 3 Ulimited $5 milllio For your group to be eligible for the $35 POS Pla, the $40/$1,000 PPO Pla, or the $40/$2,500 PPO Pla with HSA Optio, you must have Kaiser Permaete as your sole carrier, ad the pla must be offered with at least oe copaymet or deductible HMO pla as part of a multiple pla offerig. If you iclude a PPO or POS pla i your multiple pla offerig, at least 70 percet of all employees erolled i the Health Pla must be erolled i a copaymet or deductible HMO pla, ad combied erollmet i KPIC medical plas must ot exceed 30 percet. See foototes ad other importat iformatio o pages 11 ad %

13 otes for the Kaiser Permaete $40/$1,000 PPO isurace pla Kaiser Permaete plas do ot iclude a pre-existig coditio clause. * Based o maximum allowable charge for covered services Paymets are based upo the maximum allowable charge for covered services. Maximum allowable charge meas the lesser of: the usual, customary, ad reasoable charges; or the egotiated rate; or the actual billed charges. The maximum allowable charge may be less tha the amout actually billed by the provider. Covered persos may be resposible for paymet of ay amouts i excess of the maximum allowable charge for a covered service. 1 Caledar-year deductible amouts are combied for services provided by PHCS etwork ad oparticipatig providers. Deductibles do ot cout toward satisfyig the out-of-pocket maximum. This pla carries a embedded deductible. Each family member becomes eligible for beefits after meetig the idividual deductible, or whe the family deductible is satisfied. A family member ca meet the idividual aual out-of-pocket maximum before the family out-of-pocket maximum is satisfied. 2 Covered charges icurred toward satisfactio of the out-of-pocket maximum at the oparticipatig providers tier will ot accumulate toward satisfactio of the out-of-pocket maximum o the PHCS etwork tier. Likewise, covered charges icurred toward satisfactio of the out-of-pocket maximum at the PHCS etwork tier will ot accumulate toward satisfactio of the out-of-pocket maximum o the oparticipatig providers tier. 3 Maximum beefit while isured applies to chages from oparticipatig providers oly. 4 Kaiser Permaete Isurace Compay (KPIC) pays a maximum of $600 per day combied for all hospital care received from oparticipatig providers, excludig physicia, surgeo, ad surgical services. 5 Brad-ame drug deductible, copaymets, ad coisurace paid for physicia office visit or paid for prescriptios filled at participatig pharmacies are ot subject to, or do they cotribute toward, satisfactio of either the caledar-year deductible or the out-of-pocket maximum. 6 This service is ot subject to a deductible. 7 Routie adult physical exams are limited to oe exam every 12 moths. Prevetive lab tests, X-ray, ad immuizatios are covered as part of the prevetive exam. 8 Well-child prevetive care icludes immuizatios. 9 Kaiser Permaete Isurace Compay pays a maximum of $400 per procedure for outpatiet surgery services from oparticipatig providers. 10 All outpatiet therapies are limited to 60 visits per caledar year combied for both PHCS etwork ad oparticipatig providers. 11 The PHCS etwork does ot cotract for ambulace service. Therefore, medically ecessary oemergecy ambulace service is payable at the oparticipatig providers level. Noemergecy ambulace coverage is limited to a maximum of $2,000 per caledar year for all services. 12 Member is resposible for payig the brad-ame copay plus the differece i cost betwee the geeric drug ad the brad-ame drug whe the patiet requests a brad-ame drug ad a geeric versio is available. 13 MedImpact pharmacy copaymets are ot subject to, or do they cotribute toward satisfactio of, the caledar-year deductible or the out-of-pocket maximum. Select prescriptio drugs are excluded from coverage. 14 Self-admiistered ijectable medicatios are limited to a 30-day maximum supply ad are ot available uder the mail-order service. Prescriptios for isuli are covered at the brad-ame or geeric copaymet level. 15 Combied maximum deductible of $50 per caledar year 16 Beefits payable for treatmet of ifertility are limited to $1,000 per caledar year combied for services provided by PHCS etwork or oparticipatig providers. I vitro fertilizatio is ot covered. Beefits payable for diagosis of ifertility will be covered o the same basis as ay other illess. 17 Certai durable medical equipmet ad supplies are limited to $2,000 maximum beefit per caledar year for services from oparticipatig providers, excludig diabetic testig supplies ad equipmet. 18 Diabetic equipmet ad supplies are limited to ifusio set ad syrige with eedle for exteral isuli pumps, testig strips, lacets, ski barrier, adhesive remover wipes, ad trasparet film. Coisurace amouts are based o actual billed charges ad are ot subject to the DME aual maximum limit of $2,000 per caledar year. 11

14 Notes for Kaiser Permaete pos ad ppo plas Precertificatio of services provided by PHCS etwork ad oparticipatig providers Precertificatio is required for all hospital cofiemets, icludig preadmissio testig; ipatiet care at a skilled ursig facility or other licesed, freestadig facilities, such as hospice care, home health care, or care at a rehabilitatio facility; ad select outpatiet procedures. Failure to obtai precertificatio will result i a additioal deductible of $500 per occurrece for covered charges icurred i coectio with these services. This additioal deductible will ot cout toward the satisfactio of ay caledar-year deductibles or out-of-pocket maximums. PHCS etwork ad oparticipatig providers Uless specifically covered uder the group policy, expeses icurred i coectio with the followig services are excluded: charges, services, or care that are provided or reimbursed by Kaiser Foudatio Health Pla; ot medically ecessary; i excess of the maximum allowable charge; ot available i the Uited States; for persoal comfort. Emergecy Departmet facility fees or charges for oemergecy weeked (Friday through Suday) hospital admissios. Charges arisig from work or that ca be covered uder workers compesatio or ay similar law, or for which the group policyholder or member is required by law to maitai alterative isurace or coverage. Charges for military service-related coditios or where care is provided at govermet expese. Services or care provided i a member s home, by a family member, or by a residet of the household. Detal care, appliaces, or orthodotia, uless due to ijury to atural teeth. Cosmetic services; plastic surgery; sex trasformatio; sexual dysfuctio; surrogacy arragemets; biotechology drugs or diagostics; oprescriptio drugs or medicies; treatmet, procedures, or drugs Kaiser Permaete Isurace Compay determies to be experimetal or ivestigatioal. Educatio, couselig, therapy, or care for learig deficiecies or behavioral problems. Services, care, or treatmet of or i coectio with obesity or weight maagemet. Services, care, or treatmet of or i coectio with craiomadibular or temporomadibular joit disorders, uless for medically ecessary surgical treatmet of the disorder. Services, care, or treatmet of or i coectio with musculoskeletal therapy; health educatio; biofeedback; hypotherapy; routie adult physical exams; immuizatios; medical social services; hearig exams, aids, or therapy; radial keratotomy or similar procedures; reversal of sterilizatio; or routie foot care. Services or care required by a court of law or for isurace, travel, employmet, school, camp, govermet licesig, or similar purposes. Trasplats, icludig door costs. Custodial care; care i a itermediate care facility; maiteace therapy for rehabilitatio; or livig or trasportatio expeses. Treatmet of metal illess; substace abuse. Services or supplies ecessary to treat a ijury to which a cotributig cause was a member s: commissio of or attempt to commit a feloy; egagemet i a illegal occupatio; itoxicatio; or uder the ifluece of a arcotic, uless admiistered by a physicia. Services of a private-duty urse. Visio care, icludig routie exams, eye refractios, orthoptics, glasses, cotact leses, or fittigs; drugs ad medicie for smokig cessatio; well-child care ad immuizatios. Exteded well-child care. Services for which o charge is ormally made i the absece of isurace. Importat iformatio Writte iformatio o topics related to coverage offered to employer groups i the small group market is available ad ca be obtaied by cotactig your broker or your sales represetative. Topics iclude: 1. Factors that affect rate settig ad rate adjustmets 2. Provisios related to reewig coverage 3. Geographic areas covered by the Health Pla Notes for ALL plas Kaiser Permaete plas do ot iclude a pre-existig coditio clause. The copaymet plas, HSA-qualified deductible HMO plas, deductible HMO plas, deductible HMO plas with HRA, ad the i-etwork portio of the poit-of-service (POS) pla are uderwritte by Kaiser Foudatio Health Pla, Ic. (KFHP). Kaiser Permaete Isurace Compay (KPIC), a subsidiary of KFHP, uderwrites the PPO pla ad the out-of-etwork portio of the POS pla as well as the Delta Detal of Califoria detal plas. The chiropractic beefit is admiistered by America Specialty Health Plas of Califoria, Ic. The chiropractic/ acupucture beefit is admiistered by Private Healthcare Systems. This booklet is a summary oly. The Kaiser Foudatio Health Pla Evidece of Coverage ad the KPIC Certificate of Isurace cotai a complete explaatio of beefits, exclusios, ad limitatios. The iformatio provided i this brochure is ot iteded for use as a beefit summary, or is it desiged to serve as the Evidece of Coverage or Certificate of Isurace. 12

15 Detal plas 2011 Small Busiess Effective Jauary to Jue 2011

16 Delta Detal Premier Effective 1/1/11 6/1/11 Pla C Pla D Pla E Pla E with Ortho 1 Limitatios Service Pla pays 2 Pla pays 2 Pla pays 2 Pla pays 2 No deductible applies to these procedures. Exam 100% 100% 100% 100% Twice i a caledar year Bitewig X-rays X-rays of the top ad bottom molars ad premolars to show decay betwee teeth or uder filligs 100% 100% 100% 100% Twice i a caledar year for childre through age 18, or oce i a caledar year for adults ages 19 ad over Other X-rays 80% 80% 80% 80% Full-mouth X-rays, sigle X-rays, ad paographic X-rays oce i ay five-year period Prophylaxis a professioal cleaig to remove plaque, calculus (mieralized plaque), ad stais to help prevet detal disease Fluoride treatmets a treatmet with a chemical compoud that prevets cavities ad makes the tooth surface stroger so the teeth ca resist decay 100% 100% 100% 100% Twice i a caledar year 100% 100% 100% 100% Oly for childre through age 18, twice i a caledar year Deductibles apply to procedures uder plas D, E, ad E with Orthodotics. Caledar-year deductible No deductible $25 $25 $25 Per perso per caledar year up to a family maximum of $75 per caledar year Aual beefit maximum $500 $1,000 $1,000 $1,000 Aual beefit maximum represets the total aual amout paid by the pla Palliative care ay form of medical care or treatmet that cocetrates o reducig the severity of disease symptoms; the goal is to prevet ad relieve sufferig ad improve quality of life 80% 80% 80% 80% Usual, customary, ad reasoable Deture relies 80% 80% 80% Twice i a caledar year (limited to two upper, two lower, or ay combiatio) 3 Space maitaiers 100% 100% 100% 100% Usual, customary, ad reasoable Filligs 80% 80% 80% 80% Usual, customary, ad reasoable Stailess steel crows 80% 80% 80% 80% Primary teeth oly Edodotics a detal specialty cocered with treatmet of the root ad erve of the tooth 80% 80% 80% Usual, customary, ad reasoable Periodotics a detal specialty cocered with the treatmet of gums, tissue, ad boe that supports the teeth 80% 80% 80% Usual, customary, ad reasoable Oral surgery 80% 80% 80% Usual, customary, ad reasoable Crows ad cast restoratios the artificial coverig of a tooth with metal porcelai or porcelai fused to metal; covers teeth that are weakeed by decay or severely damaged or chipped Prosthodotics a detal specialty cocered with restoratio ad/or replacemet of missig teeth with artificial materials Orthodotics a detal specialty cocered with straighteig or movig misaliged teeth ad/or jaws with braces ad/or surgery Icludes replacemets after five years, but oly if origially covered by KPIC detal pla Stadard removable prosthetic appliace (icludes replacemets after five years, but oly if origially covered by KPIC detal pla) For eligible depedet childre through age 18, $1,500 lifetime maximum per isured (Replacemet or repair of a orthodotic appliace paid for i part or i full by this pla is ot covered.) 1 Pla E with Orthodotics requires at least 10 subscribers. 2 Beefits payable will be based o the lesser of the usual, customary, ad reasoable fees or the fees actually charged. 3 Limitatio applies oly to Pla D. 14

17 Delta Detal PPO Effective 1/1/11 6/1/11 PPO D 1500 PPO E 1000 PPO E 1500 Limitatios PPO etwork Pla pays 3 Out-of-etwork Pla pays PPO etwork Pla pays 3 No deductible applies to these procedures. Out-of-etwork Pla pays PPO etwork Pla pays 1 Out-of-etwork Pla pays 100% 100% 100% Twice i a caledar year 100% 100% 100% Twice i a caledar year for childre through age 18, or oce i a caledar year for adults ages 19 ad over 80% 80% 80% Full-mouth X-rays, sigle X-rays, ad paographic X-rays oce i ay five-year period 100% 100% 100% Twice i a caledar year 100% 100% 100% Oly for childre through age 18, twice i a caledar year $25 $50 $25 $50 $25 $50 Per perso per caledar year up to a family maximum of $75 ad $150 uder i- ad out-of-etwork, respectively $1,500 $1,500 $1,000 $1,000 $1,500 $1,500 Aual beefit maximum represets the total aual amout paid by the pla 80% 80% 80% 80% 80% 80% Twice i a caledar year 100% 100% 100% 80% 80% 80% 80% 80% 80% Primary teeth oly 80% 80% 80% 80% 80% 80% 80% 80% 80% Icludes oe replacemet i ay five-year period, but oly if origially covered by KPIC detal pla Stadard removable prosthetic appliaces (icludes oe replacemet i ay five-year period, but oly if origially covered by KPIC detal pla) 1 Beefits payable will be based o the maximum allowable charge. 15

18 Importat iformatio for the Delta Detal Premier ad Delta Detal PPO detal isurace plas The followig services are ot covered uder ay Kaiser Permaete Isurace Compay (KPIC) group detal isurace plas: Ay treatmet or procedure ot listed as covered Charges i excess of the maximum allowable charge Services for ijuries or coditios covered uder workers compesatio or employer s liability laws Cosmetic surgery, detistry, or services to correct hereditary, cogeital, or developmetal malformatios Restoratio of tooth structure or chewig surfaces for damages due to wear Prosthodotic services or procedures started prior to a perso s date of eligibility Prescribed drugs, premedicatio, or pai relievers Experimetal procedures Hospital costs or extra charges for hospital treatmet Aesthesia (except geeral aesthesia for oral surgery) Extra-oral grafts, implats, or implat removal Treatmet related to the temporomadibular joit (TMJ) Plaque cotrol programs, oral hygiee, or dietary istructios Orthodotic treatmet, except for eligible depedet childre uder Pla E with Orthodotics Treatmet plas that are more expesive tha those customarily provided, or specialized techiques used istead of stadard procedures; for example, a precisio deture where a stadard deture would suffice Pit ad fissure sealats, except for first molars of childre through age 8 ad secod molars for childre through age 15. The molar must have o decay ad o restoratio, ad the occlusal surface must be itact. Coverage does ot iclude the repair or replacemet of a sealat o ay tooth withi three years of applicatio. Services provided to the covered perso by ay federal or state govermetal agecy or provided without cost to the covered perso by ay muicipality, couty, or other political subdivisio, except Medi-Cal beefits Charges by ay hospital or other surgical treatmet facility, or ay additioal fees charged by the detist for treatmet i ay such facility Implats (materials implated ito or o boe or soft tissue) or the repair or removal of implats Replacemet of existig restoratio for ay purpose other tha active tooth decay Itraveous sedatio, occlusal guards, or complete occlusal adjustmet Charges for replacemet or repair of a orthodotic appliace paid i part or i full by this program Hyposis Charges for completio of forms Charges for speech therapy Charges for lost or stole appliaces Services for which o charge is ormally made i the absece of isurace Predetermiatio of beefits is recommeded for services i excess of $300. This documet is ot iteded as a summary pla descriptio, or is it desiged to serve as the Certificate of Isurace or the Schedule of Coverage. It cotais oly a summary of beefits, exclusios, ad limitatios. If you have specific questios regardig beefit structure, limitatios, or exclusios, cosult the Certificate of Isurace ad the Schedule of Coverage or cotact Delta Detal s Customer Service Departmet at , 8 a.m. to 5 p.m., Moday through Friday. For a list of i-etwork providers, cotact Delta Detal s Customer Service Departmet. This detal isurace pla is uderwritte by Kaiser Permaete Isurace Compay, a subsidiary of Kaiser Foudatio Health Pla, ad admiistered by Delta Detal of Califoria. deltadetalis.com 16