Plan highlights. Effective January to June Small Business

Transcription

1 Pla highlights Effective Jauary to Jue Small Busiess

2 welcome to kaiser permaete O these pages, you ll fid a overview of available pla beefits for small busiesses. A full listig of all Kaiser Permaete plas ad beefits ca be foud i your 2010 Kaiser Foudatio Health Pla Evidece of Coverage ad your Kaiser Permaete Isurace Compay Certificate of Isurace. Why ot give them a choice? Keep your employees healthy ad happy by lettig them choose from a variety of coverage optios. After all, your compay rus well because it values the uique skills that each employee brigs to the job. Why ot offer them the ability to choose the health care pla that best meets their uique eeds ad those of their family members? Now, with Kaiser Permaete, you ca let your employees choose the pla with the right balace of optios for them. It s a busiess advatage, too. You eed a simple solutio that provides choice at the right price ad is easy to admiister. Solve the problem by providig a suite of plas from Kaiser Permaete icludig a selectio of copaymet, HSA-qualified, HRA, deductible, POS, ad PPO plas for your employees with o added expese or effort o your part. 1 1 Multiple pla offerig rules: Groups with three to five subscribers are eligible to eroll i a maximum of two Kaiser Permaete plas. Groups with six or more subscribers are eligible to eroll i oe or more plas. 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 HMO pla, ad combied erollmet i Kaiser Permaete Isurace Compay (KPIC) POS ad PPO plas must ot exceed 30 percet.

3 Cotets Copaymet plas Predictable out-of-pocket costs ad o aual deductible to meet for medical services 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 Lower mothly premiums, ad prevetive care ad doctor visits are ot subject to the deductible Deductible HMO plas with health reimbursemet arragemet (HRA) A IRS-regulated, employer-sposored program that allows your employees to receive tax-free dollars 1 from you to pay for qualified medical expeses $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 Most Popular Copaymet pla $50 Pla $30 Pla $20 Pla $15 Pla $5 Pla Member Pays Member Pays Member Pays Member Pays Member Pays Caledar-Year Deductible $0 $0 $0 $0 $0 Pharmacy Caledar-Year Deductible $250 for brad $250 for brad $0 $0 $0 prescriptios prescriptios 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 $50 $30 $20 $15 $5 Prevetive exams $50 $30 $20 $15 $5 Materity/Preatal care 2 $15 $0 $0 $0 $0 Well-child prevetive care visits 3 $15 $0 $0 $0 $0 Vaccies (immuizatios) $0 $0 $0 $0 $0 Allergy ijectios $5 $5 $5 $5 $0 Ifertility services Not covered Not covered Not covered 50% 50% Occupatioal, physical, ad speech therapy $50 $30 $20 $15 $5 Most labs ad imagig $10 $10 $10 $10 $10 MRI/CT/PET $50 $50 $50 $50 $50 Outpatiet surgery $250 per procedure $200 per procedure $150 per procedure $100 per procedure $5 per procedure Emergecy Services Emergecy Departmet visits $150 $100 $100 $100 $100 (waived if admitted directly to hospital) Ambulace $300 $75 $75 $75 $75 Prescriptios 4 (up to a 100-day supply) (up to a 100-day supply) (up to a 30-day supply) (up to a 30-day supply) (up to a 100-day supply) Geeric 5 $10 $10 $10 $10 $5 Brad-ame $35 (after pharmacy $35 (after pharmacy $30 5 $25 5 $15 5 deductible) deductible) Hospital Care Physicias services, room ad board, $500 per day $400 per day $300 per day $200 per day $0 tests, medicatios, supplies, therapies Skilled ursig facility care $0 $0 $0 $0 $0 (up to 100 days per beefit period) Effective 1/1/10 6/1/10 Metal Health Services 6 I the medical office $50 idividual $30 idividual $20 idividual $15 idividual $5 idividual (up to 20 visits per caledar year) $25 group $15 group $10 group $7 group $2 group I the hospital $500 per day $400 per day $300 per day $200 per day $0 (up to 30 days per caledar year) Chemical Depedecy Services I the medical office $50 idividual $30 idividual $20 idividual $15 idividual $5 idividual I the hospital (detoxificatio oly) $500 per day $400 per day $300 per day $200 per day $0 Other Certai durable medical equipmet (DME) Not covered 7 Not covered 7 20% 20% 20% ($2,000 maximum) ($2,000 maximum) ($2,000 maximum) Optical (eyewear) Not covered 8 Not covered 8 Not covered 8 $150 allowace 9 $150 allowace 9 Visio exam $50 $30 $20 $15 $5 Home health care $0 $0 $0 $0 $0 (up to 100 two-hour visits per caledar year) Hospice care $0 $0 $0 $0 $0 Kaiser Permaete plas do ot iclude a pre-existig coditio clause. 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 Visit or day limits do ot apply to serious emotioal disturbaces of childre ad severe metal illesses as described i the Evidece of Coverage. 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 kp.org/2020 for Kaiser Permaete optical locatios. 9 Allowace toward the cost of eyeglass leses, frames, ad cotact leses fittig ad dispesig every 24 moths 2

5 KAISER PERMANENTE HSA-Qualified Deductible HMO plas Pla Highlights Features Effective 1/1/10 6/1/10 Most Popular Deductible pla $30/$3,000 Pla w/hsa $0/$2,700 Pla w/hsa $0/$2,000 PLAN w/hsa Member Pays member Pays 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 $30 (after deductible) $0 (after deductible) $0 (after deductible) Prevetive exams 4 $30 $0 $0 Materity/Preatal care 4,5 $10 $0 $0 Well-child prevetive care visits 4,6 $10 $0 $0 Vaccies (immuizatios) 4 $0 $0 $0 Allergy ijectios $5 (after deductible) $0 (after deductible) $0 (after deductible) Ifertility services Not covered Not covered Not covered Occupatioal, physical, ad speech therapy $30 (after deductible) $0 (after deductible) $0 (after deductible) Most labs ad imagig $10 (after deductible) $0 (after deductible) $0 (after deductible) MRI/CT/PET $50 (after deductible) $50 (after deductible) $50 (after deductible) Outpatiet surgery 30% (after deductible) $250 (after deductible) $150 (after deductible) Emergecy Services Emergecy Departmet visits 30% (after deductible) $100 (after deductible) $100 (after deductible) (waived if admitted directly to hospital) Ambulace $100 (after deductible) $100 (after deductible) $100 (after deductible) Prescriptios 7 (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) Geeric $10 (after deductible) $10 (after deductible) $10 (after deductible) Brad-ame $30 (after deductible) $30 (after deductible) $30 (after deductible) Hospital Care Physicias services, room ad board, tests, 30% per admissio $450 per day $300 per day medicatios, supplies, therapies (after deductible) (after deductible) (after deductible) Skilled ursig facility care 30% per admissio $0 per admissio $0 per admissio (up to 100 days per beefit period) (after deductible) (after deductible) (after deductible) Metal Health Services 8 I the medical office $30 (after deductible $0 (after deductible $0 (after deductible (up to 20 visits per caledar year) for idividual therapy) for idividual therapy) for idividual therapy) $15 (after deductible $0 (after deductible $0 (after deductible for group therapy) for group therapy) for group therapy) I the hospital 30% per admissio $450 per day $300 per day (up to 30 days per caledar year) (after deductible) (after deductible) (after deductible) Chemical Depedecy Services I the medical office $30 (after deductible $0 (after deductible $0 (after deductible for idividual therapy) for idividual therapy) for idividual therapy) I the hospital (detoxificatio oly) 30% per admissio $450 per day $300 per day (after deductible) (after deductible) (after deductible) Other Certai durable medical equipmet (DME) 9 Not covered Not covered Not covered Optical (eyewear) 10 Not covered Not covered Not covered Visio exam $30 (after deductible) $0 (after deductible) $0 (after deductible) Home health care $0 (after deductible) $0 (after deductible) $0 (after deductible) (up to 100 two-hour visits per caledar year) Hospice care $0 (after deductible) $0 (after deductible) $0 (after deductible) Kaiser Permaete plas do ot iclude a pre-existig coditio clause. 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 Visit or day limits do ot apply to serious emotioal disturbaces of childre ad severe metal illesses as described i the Evidece of Coverage. 9 Please refer to the Evidece of Coverage for more iformatio; most DME is ot covered. 10 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 kp.org/2020 for Kaiser Permaete optical locatios. 3

6 KAISER PERMANENTE Deductible HMO plas Pla Highlights Effective 1/1/10 6/1/10 Features $40/$2,000 PLAN MEMBER PAYS $30/$1,500 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 $40 $30 $30 Prevetive exams 3 $40 $30 $30 Materity/Preatal care 3,4 $0 $0 $0 Well-child prevetive care visits 3,5 $0 $0 $0 Vaccies (immuizatios) 3 $0 $0 $0 Allergy ijectios $5 (after deductible) $5 (after deductible) $5 (after deductible) Ifertility services Not covered Not covered Not covered Occupatioal, physical, ad speech therapy $40 (after deductible) $30 (after deductible) $30 (after deductible) Most labs ad imagig $10 (after deductible) $10 (after deductible) $10 (after deductible) MRI/CT/PET $50 (after deductible) $50 (after deductible) $50 (after deductible) Outpatiet surgery 30% (after deductible) $250 (after deductible) $250 (after deductible) Emergecy Services Emergecy Departmet visits 30% (after deductible) $100 (after deductible) $100 (after deductible) (waived if admitted directly to hospital) Ambulace $100 (after deductible) $75 (after deductible) $75 (after deductible) Prescriptios 3,6 (up to a 30-day supply) (up to a 30-day supply) (up to a 30-day supply) Geeric $10 $10 $10 Brad-ame $35 $30 $30 Hospital Care Physicias services, room ad board, tests, 30% per admissio $500 per day $500 per day medicatios, supplies, therapies (after deductible) (after deductible) (after deductible) Skilled ursig facility care (up to 60 days per beefit period) 30% per admissio (after deductible) $50 per day (after deductible) $50 per day (after deductible) Metal Health Services 7 I the medical office 3 $40 (for idividual therapy) $30 (for idividual therapy) $30 (for idividual therapy) (up to 20 visits per caledar year) $20 (for group therapy) $15 (for group therapy) $15 (for group therapy) I the hospital 30% per admissio $500 per day (after deductible) $500 per day (after deductible) (up to 30 days per caledar year) (after deductible) Chemical Depedecy Services I the medical office 3 $40 (for idividual therapy) $30 (for idividual therapy) $30 (for idividual therapy) I the hospital (detoxificatio oly) 30% per admissio $500 per day (after deductible) $500 per day (after deductible) (after deductible) Other Certai durable medical equipmet (DME) 8 30% per item Not covered Not covered Optical (eyewear) 9 Not covered Not covered Not covered Visio exam 3 $40 $30 $30 Home health care 3 $0 $0 $0 (up to 100 two-hour visits per caledar year) Hospice care 3 $0 $0 $0 $30/$1,000 PLAN MEMBER PAYS Kaiser Permaete plas do ot iclude a pre-existig coditio clause. 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 Visit or day limits do ot apply to serious emotioal disturbaces of childre ad severe metal illesses as described i the Evidece of Coverage. 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 kp.org/2020 for Kaiser Permaete optical locatios. 4

7 KAISER PERMANENTE Deductible HMO plas with HRA Pla Highlights Effective 1/1/10 6/1/10 Features $30/$2,500 PLAN WITH HRA $30/$1,500 PLAN WITH HRA member Pays 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/$10,000 $3,500/$7,000 I the Medical Office Office visits $30 (after deductible) $30 (after deductible) Prevetive exams 3 $30 $30 Materity/Preatal care 3,4 $10 $10 Well-child prevetive care visits 3,5 $10 $10 Vaccies (immuizatios) 3 $0 $0 Allergy ijectios $0 (after deductible) $0 (after deductible) Ifertility services Not covered Not covered Occupatioal, physical, ad speech therapy $30 (after deductible) $30 (after deductible) Most labs ad imagig $10 (after deductible) $10 (after deductible) MRI/CT/PET $50 (after deductible) $50 (after deductible) Outpatiet surgery 20% (after deductible) 20% (after deductible) Emergecy Services Emergecy Departmet visits 20% (after deductible) 20% (after deductible) (waived if admitted directly to hospital) Ambulace $150 (after deductible) $150 (after deductible) Prescriptios 6 (up to a 30-day supply) (up to a 30-day supply) Geeric 3 $10 $10 Brad-ame $30 $30 Hospital Care Physicias services, room ad board, tests, 20% per admissio (after deductible) 20% per admissio (after deductible) medicatios, supplies, therapies Skilled ursig facility care 20% per day (after deductible) 20% per day (after deductible) (up to 100 days per beefit period) (up to 100 days per beefit period) Metal Health Services 7 I the medical office $30 (after deductible for idividual therapy) $30 (after deductible for idividual therapy) (up to 20 visits per caledar year) $15 (after deductible for group therapy) $15 (after deductible for group therapy) I the hospital 20% per admissio (after deductible) 20% per admissio (after deductible) (up to 30 days per caledar year) Chemical Depedecy Services I the medical office $30 (after deductible for idividual therapy) $30 (after deductible for idividual therapy) I the hospital (detoxificatio oly) 20% per admissio (after deductible) 20% per admissio (after deductible) Other Certai durable medical equipmet (DME) 8 Not covered Not covered Optical (eyewear) 9 Not covered Not covered Visio exam 3 $30 $30 Home health care 3 $0 $0 (up to 100 two-hour visits per caledar year) Hospice care 3 $0 $0 Kaiser Permaete plas do ot iclude a pre-existig coditio clause. 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 Visit or day limits do ot apply to serious emotioal disturbaces of childre ad severe metal illesses as described i the Evidece of Coverage. 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 kp.org/2020 for Kaiser Permaete optical locatios. 5

8 KAISER PERMANENTE $35 POS Pla Pla Highlights Effective 1/1/10 6/1/10 Features Caledar-Year Deductible 1 Idividual/Family $0 Pharmacy Caledar-Year Deductible $0 $0 Not covered Aual Out-of-Pocket Maximum 2,3 Idividual/Family $3,000/$6,000 $3,000/$9,000 4 $6,000/$18,000 4 Maximum Beefit while isured Ulimited I the Medical Office Office visits $35 $45 50% Routie adult physical exams $35 $45 Not covered Adult prevetive screeig exam $35 $45 50% Materity/Preatal care 6 $0 $25 50% Well-child prevetive care visits $0 7 $ % 8 Vaccies (immuizatios) $0 Not covered Not covered Allergy ijectios $5 $25 50% Ifertility services 9 Not covered Not covered Not covered Occupatioal, physical, ad speech therapy $35 $ % 10 Most labs ad imagig $10 30% 50% MRI/CT/PET $50 30% 50% Outpatiet surgery $100 30% 50% 11 Emergecy Services Emergecy Departmet visits $100 (waived if admitted directly to hospital) Ambulace $75 Kaiser Permaete Pla providers (HMO) (i-etwork) Member Pays PHCS providers (PPO)* Member Pays $500/$1,500 $2 millio 5 Prescriptios 12 Obtaied at Kaiser Permaete Obtaied at participatig Obtaied at o Kaiser Permaete (up to a 100-day supply) Pla pharmacies (icludig MedImpact pharmacies 13 ad o MedImpact pharmacies affiliated pharmacies) Geeric $10 $15 Not covered Brad-ame $35 $40 Not covered Noformulary $50 $60 Not covered Hospital Care Physicias services, room ad board, tests, $200 per day 30% 50% 15 medicatios, supplies, therapies Skilled ursig facility care 14 $0 30% 50% Metal Health Services 16 I the medical office $35 idividual therapy $45 idividual therapy 50% idividual therapy (up to 20 visits per caledar year) $17 group therapy Group therapy ot covered Group therapy ot covered I the hospital $200 per day Not covered Not covered (up to 30 days per caledar year) Chemical Depedecy Services I the medical office (couselig for depedecy; $35 idividual therapy Idividual therapy ot covered Idividual therapy ot covered medical maagemet of withdrawal symptoms) $5 group therapy Group therapy ot covered Group therapy ot covered I the hospital (medical maagemet of $200 per day Not covered Not covered withdrawal symptoms) Other Certai durable medical equipmet (DME) 17 $0 30% 18 50% 18 Prosthetics, orthotics, ad special footwear $40 Not covered Not covered Optical (eyewear) Not covered 19 Not covered Not covered Visio exam $35 Not covered Not covered Home health care $0 20% 20 20% 20 (up to 100 two-hour visits per caledar year) Hospice care $0 30% 21 50% 21 Noparticipatig providers (out-of-etwork)* Member Pays Emergecy Departmet visits ad ambulace for emergecy medical coditios are covered as a HMO beefit for services received at ay provider. 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-of-pocket 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 serious emotioal disturbaces of childre ad severe metal illesses 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 kp.org/2020 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 Caledar-Year Deductible 1 Idividual/Family $2,500/$5,000 $3,500/$7,000 Aual Out-of-Pocket Maximum 2 Idividual/Family $5,000/$10,000 $10,000/$20,000 maximum beefit while isured 3 PHCS etwork (PPO)* Features member pays member pays $5 millio hospital care Room, board, ad critical care uits 30% 50% 4 Imagig, icludig X-rays ad lab tests 30% 50% 4 Trasplats 30% 50% 4 Physicia, surgeo, ad surgical services 30% 50% Nursig care, aesthesia, ad ipatiet 30% 50% 4 prescribed drugs outpatiet care Physicia office visits $40 copay 50% Routie adult physical exams $40 copay 5,6 Not covered Adult prevetive screeig exam 5 $40 copay 50% Well-child prevetive care visits (through age 18) 7 $25 copay 50% Pediatric visits $40 copay 50% Outpatiet surgery 30% 50% 8 Allergy testig visits 30% 50% Allergy ijectio visits 30% 50% Gyecological visits $40 copay 50% Materity/Scheduled preatal care ad first 30% 50% postpartum visit Imagig, icludig X-rays 30% 50% Lab tests 30% 50% Eye exams for eyeglass prescriptios Not covered Not covered Hearig exams Not covered Not covered Occupatioal, physical, respiratory, ad 30% 50% speech therapy visits 9 Diabetic day care maagemet 30% 50% emergecy services Emergecy Departmet visits $100 copay, the 30% (copay waived if admitted) $100 copay, the 30% (copay waived if admitted) Emergecy ambulace service 30% 30% Medically ecessary oemergecy 30% 30% ambulace service 10 Noemergecy urget care 30% 30% Prescriptios 11 MedImpact pharmacy 12 No MedImpact pharmacy Geeric drugs $15 copay (maximum 30-day supply) Not covered Brad-ame drugs $35 copay (maximum 30-day supply) Not covered Self-admiistered ijectable medicatios 13 30% Not covered Mail-order geeric drugs $30 copay (maximum 100-day supply) Not covered Mail-order brad-ame drugs $70 copay (maximum 100-day supply) Not covered metal health care Ipatiet hospitalizatio Severe metal illess ad serious emotioal 30% 50% 4 disturbaces of a child 14 All other covered metal illess 15 30% 50% Outpatiet visits Severe metal illess ad serious emotioal $40 copay 50% disturbaces of a child 14 All other covered metal illess 16 30% 50% Alcohol ad chemical depedecy 17 Ipatiet hospitalizatio 15 30% 50% Outpatiet visits 16 30% 50% Additioal beefits Care i a skilled ursig facility (60-day combied 30% 50% limit per caledar year) Home health care (100-day combied limit per 20% 20% caledar year) Hospice care (180-day combied lifetime limit) 30% Not covered Ifertility services 18 30% 50% Durable medical equipmet (DME) 19 30% 50% Prosthetics, orthotics, ad special footwear 30% 50% Diabetic equipmet ad supplies 20 30% 30% Effective 1/1/10 6/1/10 Noparticipatig providers (out-of-etwork)* 8 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.

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 is combied for services provided by PHCS etwork ad oparticipatig providers. 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 ad a beefit maximum of $400 per covered exam. 7 Well-child prevetive care is exempt from deductibles ad 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 patiet requests 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 Severe metal illess is limited to the followig: schizophreia, schizoaffective disorder, bipolar disorder (maic-depressive illess), major depressive disorders, paic disorder, obsessive-compulsive disorder, pervasive developmetal disorder or autism, aorexia ervosa, ad bulimia ervosa. 15 Beefits for treatmet of other covered metal illesses ad alcohol ad drug depedecy are limited to 20 ipatiet days per caledar year combied for both PHCS etwork ad oparticipatig providers. Kaiser Permaete Isurace Compay pays a maximum of $175 per day for ipatiet hospital care received from oparticipatig providers. 16 Beefits for treatmet of other covered metal illesses ad alcohol ad drug depedecy are limited to 20 outpatiet visits per caledar year combied for both PHCS etwork ad oparticipatig providers. 17 I additio to the specified day ad visit limit oted above, beefits payable for treatmet of alcohol ad drug depedecy are subject to a combied limit of $10,000 per caledar year ad $25,000 lifetime for services provided by PHCS etwork ad oparticipatig providers. 18 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. 19 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. 20 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 INSURANCE pla Pla Highlights Effective 1/1/10 6/1/10 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/$10,000 $10,000/$20,000 maximum beefit while isured 3 $5 millio hospital care Room, board, ad critical care uits 30% 50% 4 Imagig, icludig X-rays ad lab tests 30% 50% 4 Trasplats 30% 50% 4 Physicia, surgeo, ad surgical services 30% 50% Nursig care, aesthesia, ad ipatiet 30% 50% 4 prescribed drugs outpatiet care Physicia office visits $40 copay 5,6 50% Routie adult physical exams $40 copay 5,6,7 Not covered Adult prevetive screeig exam $40 copay 5,6 50% 6 Well-child prevetive care visits (through age 18) $25 copay 5,8 50% 8 Pediatric visits $40 copay 5,6 50% Outpatiet surgery 30% 50% 9 Allergy testig visits 30% 50% Allergy ijectio visits 30% 50% Gyecological visits $40 copay 5,6 50% Materity/Scheduled preatal care ad first 30% 50% postpartum visit Imagig, icludig X-rays 30% 50% Lab tests 30% 50% Eye exams for eyeglass prescriptios Not covered Not covered Hearig exams Not covered Not covered Occupatioal, physical, respiratory, ad 30% 50% speech therapy visits 10 Diabetic day care maagemet 30% Not covered emergecy services Emergecy Departmet visits $100 copay, the 30% (copay waived if admitted) $100 copay, the 30% (copay waived if admitted) Emergecy ambulace service Covered at the oparticipatig providers level 30% Medically ecessary oemergecy Covered at the oparticipatig providers level 30% ambulace service 11 Prescriptios 12 MedImpact pharmacy 13 No MedImpact pharmacy Geeric drugs $15 copay 5 (maximum 30-day supply) Not covered Brad-ame drugs deductible $200 deductible 5 Not covered (pharmacy ad mail order) Brad-ame drugs $35 copay 5 (maximum 30-day supply) Not covered Self-admiistered ijectable medicatios 14 30% 5 Not covered Mail-order geeric drugs $30 copay 5 (maximum 100-day supply) Not covered Mail-order brad-ame drugs $70 copay 5 (maximum 100-day supply) Not covered metal health care Ipatiet hospitalizatio Severe metal illess ad serious emotioal 30% 50% 4 disturbaces of a child 15 All other covered metal illess 16 30% 50% Outpatiet visits Severe metal illess ad serious emotioal $40 copay 5,6 50% disturbaces of a child 15 All other covered metal illess 17 30% 50% Alcohol ad chemical depedecy 18 Ipatiet hospitalizatio 16 30% 50% Outpatiet visits 17 $40 copay 5 Not covered Additioal beefits Care i a skilled ursig facility (60-day combied 30% 50% limit per caledar year) Home health care (100-day combied limit per 20% 20% caledar year) 19 Hospice care (180-day combied lifetime limit) 30% 50% Ifertility services 20 30% 50% Durable medical equipmet (DME) 21 30% 50% Prosthetics, orthotics, ad special footwear 30% 50% Diabetic equipmet ad supplies 22 30% 30% 10 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 12.

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 is combied for services provided by PHCS etwork ad oparticipatig providers. 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 ad $400 per caledar year. 8 Well-child prevetive care is exempt from deductibles ad 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 Severe metal illess is limited to the followig: schizophreia, schizoaffective disorder, bipolar disorder (maic-depressive illess), major depressive disorders, paic disorder, obsessive-compulsive disorder, pervasive developmetal disorder or autism, aorexia ervosa, ad bulimia ervosa. 16 Beefits for treatmet of other covered metal illesses ad alcohol ad drug depedecy are limited to 20 ipatiet days per caledar year combied for both PHCS etwork ad oparticipatig providers. Kaiser Permaete Isurace Compay pays a maximum of $175 per day for ipatiet hospital care received from oparticipatig providers. 17 Beefits for treatmet of other covered metal illesses ad alcohol ad drug depedecy are limited to 20 outpatiet visits per caledar year. 18 I additio to the specified day ad visit limits oted, beefits payable for treatmet of alcohol ad drug depedecy are subject to a combied limit of $10,000 per caledar year ad $25,000 lifetime for services provided by PHCS etwork ad oparticipatig providers. 19 Combied maximum deductible of $50 per caledar year 20 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. 21 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. 22 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 2010 Small Busiess Effective Jauary to Jue 2010

16 Delta Detal Premier Effective 1/1/10 6/1/10 Pla C Pla D Pla E Pla E Limitatios with Ortho 1 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 100% 100% 100% 100% Twice i a caledar year for childre X-rays of the top ad bottom molars ad through age 18, or oce i a caledar premolars to show decay betwee teeth or uder filligs 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 100% 100% 100% 100% Twice i a caledar year a professioal cleaig to remove plaque, calculus (mieralized plaque), ad stais to help prevet detal disease Fluoride treatmets 100% 100% 100% 100% Oly for childre through age 18, a treatmet with a chemical compoud that prevets cavities ad makes the tooth surface twice i a caledar year stroger so the teeth ca resist decay Deductibles apply to procedures uder plas D, E, ad E with Orthodotics. Caledar-year deductible No $25 $25 $25 Per perso per caledar year up to a family deductible 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 80% 80% 80% 80% Usual, customary, ad reasoable 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 Deture relies Not covered 80% 80% 80% Twice i a caledar year (limited to two upper, two lower, or ay combiatio) 4 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 Not covered 80% 80% 80% Usual, customary, ad reasoable a detal specialty cocered with treatmet of the root ad erve of the tooth Periodotics Not covered 80% 80% 80% Usual, customary, ad reasoable a detal specialty cocered with the treatmet of gums, tissue, ad boe that supports the teeth Oral surgery Not covered 80% 80% 80% Usual, customary, ad reasoable Crows ad cast restoratios Not covered Not covered 50% 50% Icludes replacemets after five years, but the artificial coverig of a tooth with metal porcelai or porcelai fused to metal; covers teeth that are oly if origially covered by KPIC detal pla weakeed by decay or severely damaged or chipped Prosthodotics Not covered Not covered 50% 50% Stadard removable prosthetic appliace a detal specialty cocered with restoratio ad/or (icludes replacemets after five years, but replacemet of missig teeth with artificial materials oly if origially covered by KPIC detal pla) Orthodotics Not covered Not covered Not covered 50% For eligible depedet childre through a detal specialty cocered with straighteig age 18, $1,500 lifetime maximum per or movig misaliged teeth ad/or jaws with braces ad/or surgery 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 Beefits payable will be based o the maximum allowable charge. 4 Limitatio applies oly to Pla D. 14

17 Delta Detal PPO Effective 1/1/10 6/1/10 PPO D 1500 PPO E 1000 PPO E 1500 Limitatios PPO etwork Out-of-etwork PPO etwork Out-of-etwork PPO etwork Out-of-etwork Pla pays 3 Pla pays Pla pays 3 Pla pays Pla pays 3 Pla pays No deductible applies to these procedures. 100% 50% 100% 50% 100% 50% Twice i a caledar year 100% 50% 100% 50% 100% 50% Twice i a caledar year for childre through age 18, or oce i a caledar year for adults ages 19 ad over 80% 50% 80% 50% 80% 50% Full-mouth X-rays, sigle X-rays, ad paographic X-rays oce i ay five-year period 100% 50% 100% 50% 100% 50% Twice i a caledar year 100% 50% 100% 50% 100% 50% 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% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% Twice i a caledar year 100% 50% 100% 50% 100% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% Primary teeth oly 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% Not covered Not covered 50% 50% 50% 50% Icludes oe replacemet i ay five-year period, but oly if origially covered by KPIC detal pla Not covered Not covered 50% 50% 50% 50% Stadard removable prosthetic appliaces (icludes oe replacemet i ay five-year period, but oly if origially covered by KPIC detal pla) Not covered Not covered Not covered Not covered Not covered Not covered Not covered 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 ad admiistered by Delta Detal of Califoria. deltadetalis.com 16

19 DeltaCare HMO detal plas Effective 1/1/10 6/1/10 Services DeltaCare DeltaCare Limitatios 10A 13B Prevetive care Periodic ad comprehesive oral evaluatio No cost No cost Twice i a caledar year Bitewig X-rays No cost No cost Twice i a caledar year for childre through age 18, or oce i a caledar year for adults ages 19 ad over Prophylaxis No cost No cost Twice i a caledar year Fluoride treatmets No cost No cost Oly for childre up to age 19, twice i a caledar year Space maitaiers $10 $50 Removable uilateral Periodotics Maiteace No cost $35 Twice i a caledar year Scalig ad root plaig No cost $50 Limited to four quadrats per caledar year Surgery osseous (icludes flap etry ad closure) $175 $300 Four or more teeth per quadrat Restorative Filligs primary or permaet amalgam No cost No cost Oe to four surfaces Composite crows resi-based $35 $145 Composite (idirect) Crow porcelai $195 $355 Ilay metallic No cost $145 Oe surface Edodotics Therapeutic pulpotomy No cost $25 Excludes fial restoratio Root amputatio No cost $70 Per root Root caal aterior $45 $95 Excludes fial restoratio Root caal molar $205 $335 Excludes fial restoratio Prosthodotics Complete deture $100 $285 The erollee must cotiue to be eligible, ad the service must be provided at the cotract detist facility where the deture was origially delivered Relie maxillary or madibular deture chairside No cost $50 Complete or partial Relie maxillary or madibular deture laboratory $35 $85 Complete or partial Oral ad maxillofacial surgery Extractio erupted tooth or exposed root No cost $5 Elevatio ad/or forceps removal Surgical removal of erupted tooth $15 $45 Orthodotics Comprehesive orthodotic child $1,700 $1,900 Child or adolescet to age 19 Comprehesive orthodotic adult $1,900 $2,100 Adults, icludig covered depedet adult childre Beefits listed above are oly a sample of provided services ad associated costs. Costs will vary. Please see your Evidece of Coverage (EOC) for a comprehesive list of all services ad costs. DeltaCare beefits are oly covered whe performed by a i-etwork Califoria DeltaCare HMO provider. 17

20 Exclusios of beefits for the DeltaCare HMO detal plas Exclusios 1. Ay procedure that is ot specifically listed uder Schedule A, Descriptio of Beefits ad Copaymets 2. Ay procedure that i the professioal opiio of the cotract detist: a. has poor progosis for a successful result ad reasoable logevity based o the coditio of the tooth or teeth ad/or surroudig structures, or b. is icosistet with geerally accepted stadards for detistry 3. Services solely for cosmetic purposes, with the exceptio of procedure D9972 (exteral bleachig, per arch), or for coditios that are a result of hereditary or developmetal defects, such as cleft palate, upper ad lower jaw malformatios, cogeitally missig teeth, ad teeth that are discolored or lackig eamel, except for the treatmet of ewbor childre with cogeital defects or birth abormalities 4. Porcelai crows, porcelai fused to metal, cast metal or resi with metal type crows, ad fixed partial detures (bridges) for childre uder 16 years of age 5. Lost or stole appliaces icludig, but ot limited to, full or partial detures, space maitaiers, crows, ad fixed partial detures (bridges) 6. Procedures, appliaces, or restoratio if the purpose is to chage vertical dimesio, or to diagose or treat abormal coditios of the temporomadibular joit (TMJ) 7. Precious metal for removable appliaces, metallic or permaet soft bases for complete detures, porcelai deture teeth, precisio abutmets for removable partials or fixed partial detures (overlays, implats, ad appliaces associated therewith), ad persoalizatio ad characterizatio of complete ad partial detures 8. Implat-supported detal appliaces ad attachmets; implat placemet, maiteace, or removal; ad all other services associated with a detal implat 9. Cosultatios for ocovered beefits 10. Detal services received from ay detal facility other tha the assiged cotract detist, a preauthorized detal specialist, or a cotract orthodotist except for Emergecy Services as described i the cotract ad/or Evidece of Coverage 11. All related fees for admissio, use, or stays i a hospital, outpatiet surgery ceter, exteded care facility, or other similar care facility 12. Prescriptio drugs 13. Detal expeses icurred i coectio with ay detal or orthodotic procedure started before the erollee s eligibility with the DeltaCare USA program. Examples iclude: teeth prepared for crows, root caals i progress, full or partial detures for which a impressio has bee take, ad orthodotics uless qualified for the orthodotic treatmet i progress provisio 14. Lost, stole, or broke orthodotic appliaces 15. Chages i orthodotic treatmet ecessitated by accidet of ay kid 16. Myofuctioal ad parafuctioal appliaces ad/or therapies 17. Composite or ceramic brackets, ligual adaptatio of orthodotic bads, ad other specialized or cosmetic alteratives to stadard fixed ad removable orthodotic appliaces 18. Treatmet or appliaces that are provided by a detist whose practice specializes i prosthodotic services For additioal beefit iformatio or a directory of Delta detists, please call Delta Detal toll free at deltadetalis.com

21 Chiropractic beefits 2010 Small Busiess Effective Jauary to Jue 2010