Provider Manual. Member Eligibility and Benefits Determination Product Descriptions Drug Benefits and Formulary

Provider Manual Member Eligibility and Benefits Determination Product Descriptions Drug Benefits and Formulary 8/31/2012

Welcome To Kaiser Permanente This section of the Provider Manual was created to help guide you and your staff in working with Kaiser Permanente s Member eligibility and benefit determination policies and procedures. It provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services related to Member eligibility and benefit determination. This Section also briefly describes our products. If at any time you have a question or concern about the information outlined in this Section of the Provider Manual, you can reach our Member/Provider Services Department by calling (303) 338-3800 for Denver/Boulder and (888) 681-7878 for Southern Colorado. 8/31/2012

Table of Contents SECTION 3: MEMBER ELIGIBILITY AND BENEFITS DETERMINATION... 3.1 MEMBER ELIGIBILITY VERIFICATION... 4 3.2 RETROACTIVE ELIGIBILITY CHANGES... 5 3.3 BENEFIT COVERAGE VERIFICATION... 5 3.4 EXCLUSIONS AND LIMITATIONS... 6 3.5 PRODUCTS AND ID CARDS... 6 3.5.1 HMO Products... 6 3.5.1.1 Member ID Cards for HMO... 11 3.5.2 Point-of-Service ( POS ) Products... 13 3.5.2.1 Member ID Cards for POS... 17 3.5.3 PPO Products... 20 3.5.3.1 PPO Member ID Cards... 21 3.5.4 Medicare Products... 27 3.5.4.1 Member ID Cards... 28 3.5.5 Self-Funded (SF) Product... 29 3.5.5.1 Member ID Card... 29 3.5.6 Medicaid Product... 29 3.5.6.1 Member ID Card... 29 3.6 PRECERTIFICATION REQUIREMENTS... 29 3.6.1 POS Precertification Requirements.....29 3.6.2 PPO Precertification Requirements.....31 3.6.3 KPIC Precertification Requirements....32 3.7 DRUG BENEFITS AND FORMULARY... 33 3.7.1 Kaiser Permanente Participating Network Pharmacies:... 35 3.7.2 Physician Access : Southern Colorado Only... 40 3.8 VISITING MEMBERS... 41 12/14/2012 3

Section 3: Member Eligibility and Benefits Determination 3.1 Member Eligibility Verification You are responsible to verify a Member s eligibility each time the Member presents at your office for services. Do not assume that coverage is in effect because a person produces a Kaiser Permanente Member ID card. The process for verifying eligibility is as follows: 1. Request Kaiser Permanente Member ID card and check identity against a photo ID. 2. Contact Kaiser Permanente by telephone, interactive voice response (IVR) system or by web, as described in the chart below 3. If you cannot verify eligibility because Kaiser Permanente s eligibility verification systems are closed, you should verify eligibility on the next business day. If Kaiser Permanente is unable to verify eligibility or if services are requested after hours, you must ask the person to complete a financial responsibility form, and explain that the person will be responsible to pay for the services if it is later determined that he or she did not have coverage on the date of service. See Section 3.2 of the Manual regarding retroactive eligibility changes. To confirm a Member s current PCP or to verify eligibility, choose one of the options below. Example: Option Description #1 Interactive Voice Response (IVR) System: The IVR can be accessed for member eligibility, copayment information, and the name of the PCP assigned to the member through the Member/Provider Services Department for Denver/Boulder (303) 338-3800 and Southern Colorado (888) 681-7878, Mon-Sun from 8am to 5pm. Please have the member s ID number and date of birth available when you call. Interactive Voice Response -- Non KP Letter #2 Member/Provider Service Line: If you are unable to use the IVR system to confirm member eligibility or PCP assignment, you may speak with a customer service representative by calling the Member/Provider Services Department Line for Denver/Boulder (303) 338-3800 and Southern Colorado (888) 681-7878, M-F from 8am to 5pm. Please provide the member s name and member ID number, inclusive of suffix, which is located on the Kaiser Permanente ID card. 12/14/2012 4

Option Description #3 www.providers.kp.org/cod: Eligibility verification is available to providers via AffiliateLink the Kaiser Permanente website at www.providers.kp.org/cod, a secured site, for which a user ID number and password are required. To obtain access, call (303) 338-3216. 3.2 Retroactive Eligibility Changes Kaiser Permanente may determine retroactively that a person was not eligible for coverage on the date of service. This occurs, for example, when eligibility data is received late from employer groups, or is adjusted by employer groups. The applicable Payor is not responsible to pay for services in that case, but if you obtained a financial responsibility form from the person, you may bill the person directly for the services. If you have already received payment for the services, the applicable Payor will notify you of the adjustment. Member eligibility may change retroactively in the following conditions: Kaiser Permanente receives delayed information, e.g., from Member s employer, that an individual is no longer a Member The individual policy/benefit contract has been terminated The Member decides not to purchase continuation coverage The eligibility information received by Kaiser Permanente is later determined to be false. If you have received payment on a claim(s) that is impacted by a retroactive eligibility change, a claim adjustment will be made. The reason for the claim adjustment will be reflected on the remittance advice. 3.3 Benefit Coverage Verification You are responsible for verifying that a Member has coverage under his or her Membership Agreement for the services you will be providing, and for obtaining any required prior authorization. See Section 4 of the Manual for information regarding authorization requirements. To determine a member s benefit coverage, choose on the options below. 1. Contact the Member/Provider Services Department for Denver/Boulder 303-338- 3800 and Southern Colorado 888-681-7878 to verify member benefit coverage. 2. Access member benefit coverage via AffiliateLink website at www.providers.kp.org/cod a secured site, for which a user ID number and password are required. To obtain access, call 303-338-3216 12/14/2012 5

3.4 Exclusions and Limitations The benefits described in each Membership Agreement are subject to various limitations and exclusions. It is important to inquire about coverage before rendering a service so the Member can be informed of potential payment responsibility. Information can be obtained by calling for Denver/Boulder 303-338-3800 and Southern Colorado 888-681-7878. 3.5 Products and ID Cards Kaiser Permanente of Colorado offers different products to individuals and employer groups. The Member s identification card will indicate which product he/she is enrolled in. Kaiser Permanente members should present their ID cards prior to services. Additionally, it is recommended you obtain a copy of the card (front and back) each time services are rendered. This will assist you in referencing required insurance information. You are contracted to treat Kaiser Permanente Members who are enrolled in the following plans: HMO Products: Traditional HMO Product Traditional HMO Medicare Product(s) Deductible / Coinsurance HMO (DHMO) Deductible Product with Health Savings Account (DPHSA) HMO Plus Deductible Coinsurance HMO Plus Medicare Senior Advantage Plus Choice Plan (HMOPOS) Point of Service (POS) Products Added Choice Products Added Choice POS: HMO + Indemnity Added Choice Triple Option: HMO + PPO + Indemnity Added Choice Deductible Coinsurance: DHMO + PPO + Indemnity MultiChoice POS PPO Products: Traditional PPO PPO with Health Savings Account (HSA) Out-of-Area PPO 3.5.1 HMO Products Traditional HMO Product Our Traditional HMO product covers Kaiser Permanente s largest membership. With this product our members choose Primary Care Physicians within the Colorado 12/14/2012 6

Permanente Medical Group and receive almost all of their care within the Kaiser Permanente traditional Group Model System. A referral from a CPMG physician is required to obtain services outside of the traditional system. Within this product, Kaiser Permanente offers a wide selection of benefit choices. To verify eligibility and benefit information only, contact The Member Services for Denver/Boulder (303)-338-3800 and Southern Colorado (888) 681-7878 or e-mail: colorado.cs@kp.org. Deductible / Coinsurance HMO Product (DHMO) Deductible/Coinsurance HMO has been part of the Kaiser Permanente portfolio since January 1, 2004. DHMO is available for large group, small group and individual lines of business. DHMO products are based on our core HMO plan but with a deductible that results in a lower monthly premium. Members have access to any Kaiser Permanente physician. Preventive services (defined in DPHSA section) are covered at no extra charge. Copayments apply to doctor s visits and prescriptions. The member must meet a deductible for certain procedures, hospitalization and outpatient surgery before coinsurance begins. Copayments and the deductible do not count toward meeting the out-of-pocket maximum. Deductible The amount a member must pay in a calendar (or contract) year for certain services before coinsurance begins. Members must pay full charges when they receive specified services until they meet their deductibles. Kaiser Permanente s DHMO plans have deductibles that range from $250-$2,000 per individual per year and $750-$6,000 per family per year. The following services are subject to these deductibles: Procedures received during an office visit or scheduled procedure visit. o Outpatient surgery services. o Inpatient hospital services. o Inpatient medical detoxification, including chemical dependency residential rehabilitation. o Dialysis services. o Emergency services. o Non-emergency, non-routine procedures received after hours. o Home health services. o Hospice services. o Inpatient psychiatric hospitalization services. o Inpatient treatment in a multidisciplinary rehabilitation program. o Skilled nursing facility services. o Diagnostic and therapeutic X-ray services. o Special procedures such as CT, PET, MRI and nuclear medicine. Coinsurance A percentage of the charges members must pay when they receive a covered service and have already met the terms of their deductible. Coinsurance will be 10, 20 or 30 %, depending on the plan option. For example, if the plan calls for the 12/14/2012 7

member to pay 20 % of the total charge of an eligible service, Kaiser Permanente would pay 80 % or the remaining charge. The coinsurance applies to contracted, not billed, charges. Out-of-pocket maximum Limits the total amount of coinsurance a member must pay over the course of a single year. For example, a deductible/coinsurance plan might have an out-of-pocket maximum of $2,000. Once a member has paid their deductible and that amount in coinsurance within a single year, Kaiser Permanente would pay 100 % of the cost of eligible services after that. Copayment These policies also include copayments for office visits. Primary care office visit copayments range from $15 to $35. Specialist office visit copayments range from $35 to $55. Copayments do not apply to the medical deductible. Copayments do not apply to the Out-of-Pocket maximum. Contract Financial Terms Affiliated providers of Kaiser Permanente are responsible for collecting the member s liability for copayments, deductible and coinsurance arising from visits or services rendered by you that resulted in these liabilities. Kaiser Permanente members will be responsible for copayments at the medical office visit. For deductible and coinsurance, we ask that you submit claims to Kaiser Permanente. We will determine the member s financial responsibility by calculating their deductible, coinsurance and out-of-pocket maximum. We ask that you bill the member directly for financial liabilities resulting from deductible and coinsurance. The member s liability will be based on the provider s contracted amount with Kaiser Permanente. A provider may call Kaiser Permanente s Member Services at (303) 338-3800, option 3 regarding any questions on the member's current accumulation towards their deductible or out-of-pocket maximum limits. Deductible Product with HSA Options (DPHSA) Kaiser Permanente introduced Deductible Plans with HSA Options on January 1, 2005. For Denver/Boulder, the product is offered to large group, small group and individual lines of business. In Southern Colorado, the product is offered to both small group and large group lines of business. Members are responsible for all medical costs, excluding preventive which is covered at no cost, until reaching their deductible. Deductibles and coinsurance apply to the out-of-pocket maximum. Deductible The amount a member must pay in a calendar year for services. For this plan, the first dollar applies to the deductible. Members must pay full charges when they receive services until they meet their deductibles, and then some members pay coinsurance amounts until the out-of-pocket maximum is met. Current plans have individual deductibles ranging from $1,500 to $3,000 per year and family deductibles 12/14/2012 8

ranging from $3,000 to $6,000 per year. All services are subject to the deductibles EXCEPT Preventive services (defined below). Beginning January 1, 2006, per federal regulations, DPHSA members must pay full charges for pharmacy until they meet their deductible. Depending on the benefit plan, some members will pay pharmacy copays until their out-of-pocket maximum is met. Coinsurance A percentage of the charges members must pay when they receive a covered service and have already met the terms of their deductible. Coinsurance will be 10 or 20 %, depending on the plan option. For example, if the plan calls for the member to pay 20 % of the total charge of the eligible service, Kaiser Permanente would pay 80 % or the remaining charge. Coinsurance applies to contracted, not billed, charges. Out-of-pocket maximum Limits the total amount of deductible and coinsurance dollars a member must pay over the course of a single year. For example, a plan might have an individual out-of-pocket maximum of $5,000. Once a member has paid their deductible and that amount of coinsurance within a single year, Kaiser Permanente would pay 100% of the cost of eligible services after those criteria have been met. Preventive services The following benefits have been defined as preventive, and will not apply to the deductible: o Adult Preventive Care Exam o Adult Preventive Care Screenings (tests & interpretation) o Prostrate specific antigen screening (PSA) o Fecal occult blood screening (Hemocult) o Flexible sigmoidoscopy screening o Colonoscopy screening when ordered by an MD o Cholesterol screening (lipid profile) o Fasting blood glucose test for diabetes screening o Well-Woman Care o Screening pap and interpretation o Screening mammogram and interpretation o Clinical breast exam o Chlamydia screening test and interpretation o Immunizations (excluding travel immunizations) o Well-Child Care (exams and immunizations in accordance with Medical Group guidelines) Contract Financial Terms Affiliated providers of Kaiser Permanente are responsible for collecting the member s liability for deductible and coinsurance payments arising from visits or services rendered by you that resulted in these liabilities. To check on a member s deductible balance, you may contact. Member Services at 303-338-3800, Option 3. This will enable affiliated providers to collect as accurately as possible at the point of care. 12/14/2012 9

HSA Option Kaiser Permanente members who are enrolled in these plans have the option to hold a health savings account (HSA) with an accredited financial institution. This is an investment or savings account owned by the member who can be used for healthcare expenses as defined by the I.R.S. Kaiser Permanente has named Wells Fargo as a preferred partner, although members can have an HSA with any accredited financial institution. Those members who have their HSA with Wells Fargo will be given the choice to have a Visa debit card to access their funds for healthcare services. This card works like any other Visa debit card. Below is how the debit card looks like: HMO Plus - Launched in July 2007, HMO Plus provides members the full benefits of Kaiser Permanente s HMO plus the option to receive care from any licensed physician, up to a set dollar amount each year. The set annual amount of the Plus benefit is based on Kaiser Permanente's contribution amount. Once the member reaches his Plus benefit limit, only the HMO portion of the coverage will remain. HMO Plus is available to both large and small groups. Deductible Coinsurance HMO Plus Deductible Coinsurance HMO Plus provides members all the benefits and resources of Kaiser Permanente s DHMO plan, plus the convenience to receive care from any licensed community physician at any time, up to a set dollar amount each year. The set annual amount of the Plus benefit is based on Kaiser Permanente s contribution amount. Once the member reaches his Plus benefit limit, only the Deductible Coinsurance HMO portion of the coverage will remain. Deductible Coinsurance HMO Plus is available to both large and small groups. Please refer to Physician Information Document for HMO Plus and Deductible Coinsurance HMO Plus and forms for additional information. Physician Information Document for HMO Plus 12/14/2012 10

Medicare Senior Advantage Plus Choice Plan (HMOPOS) Effective January 1, 2010, Senior Advantage Plus Choice is a Medicare Advantage HMOPOS plan with Kaiser Permanente HMO benefits and a limited out-of-network point of service (POS) benefit for out-patient services. Under the limited POS benefit Plus Choice members can self-refer to an out-patient Medicare-approved provider whether or not the provider is contracted with Kaiser Permanente. Orders written for a Plus Choice member may be performed at Kaiser Permanente medical offices; there are laboratory and radiology order forms for you to complete and fax if the member prefers to return to Kaiser Permanente for these services. Prescription drug orders must be filled at a Kaiser Permanente Denver/Boulder pharmacy for the member to receive the prescription under their Part D plan benefit. The limited annual amount of the POS benefit is based on Kaiser Permanente's contribution amount. Once the member reaches his POS benefit limit, only the HMO portion of the coverage will remain. Senior Advantage Plus Choice is only available to individuals. Provider information document for Senior Advantage Plus Choice Plan (HMOPOS) 3.5.1.1 Member ID Cards for HMO Denver/Boulder Traditional HMO Plan 12/14/2012 11

Denver/Boulder Deductible/Coinsurance HMO Plan Denver/Boulder Deductible Plan w/ HS Option Southern Colorado Traditional HMO Plan 12/14/2012 12

Southern Colorado Deductible Coinsurance HMO Plan Southern Colorado Deductible Plan w/ HS Option 3.5.2 Point-of-Service ( POS ) Products Point of Service Products (MultiChoiceSM POS, Added Choice Point of Service, Added Choice Triple Option POS, and Added Choice Deductible Coinsurance) Kaiser Permanente Insurance Company a subsidiary of Kaiser Permanente, underwrites all Out-of-Plan portions of the POS, Out-of-Area, and PPO plans. Members seeking services from providers outside of the Kaiser Permanente system can self-refer to providers of their choice at the time of medical need, or at the "point of service". They will have a Kaiser Permanente POS membership ID card. "In-Plan" If the POS member stays in-plan (using the HMO tier of his plan), obtain referral information and bill Kaiser Permanente in your usual manner. 12/14/2012 13

"Out-of-Plan" If the Added Choice member receives treatment without an HMO referral authorization, they have elected to go out-of-plan. Payment is made under the PPO or indemnity contract and all contracted discounts apply. Bill Kaiser Permanente indicating the POS member s ID number. Kaiser Permanente will send remittance advice to both you and the member itemizing the member's balance due. MultiChoice POS Effective January 1, 2008, Kaiser Permanente introduced MultiChoice, our new 3-tier Point-of-Service product. MultiChoice members have three tiers of benefits a deductible coinsurance HMO coverage for those who seek care with Kaiser Permanente or affiliated healthcare providers and medical offices, Preferred Provider coverage within the Private Healthcare Systems (PHCS) network, and Out-of-Network. Copays for office visits, deductibles, coinsurance, and out-of-pocket maximums now match between the plan s HMO and PPO coverage tiers, to reduce or eliminate benefit disparity between these networks. Added Choice Triple Option Kaiser Permanente added a PPO network option to the Added Choice product in 2001. These members have three tiers of benefits HMO, Preferred Provider Network and Out of Network. Members with three-tier POS plans like the Added Choice Triple Option plans may choose to see non-kaiser Permanente providers who are part of the Private Healthcare Systems PPO Network (PHCS), or any other licensed outside provider. Check the members ID card for applicable co-pays and coinsurance. If the out-of-plan provider is also a contracted Kaiser Permanente provider, and the member has no Kaiser Permanente referral, the claim will be handled as either a PPO or indemnity claim. The claim system will monitor appropriate PPO discounts. Note: Added Choice Triple Option and Added Choice Deductible Coinsurance products are no longer being offered to new groups with Kaiser Permanente. Contract Financial Terms - All current financial agreements apply to Kaiser Permanente members enrolled in the POS plans. However, if you have a capitation agreement these members are not included in your per member/per month calculation. They will be reimbursed at the discounted fee for service terms in your contract. You may not collect from Kaiser Permanente or the member a combination of payments greater than your contractual rate for covered services rendered to POS members. For "out-of-plan" cases, the member's deductible/coinsurance payment obligations are calculated based on your contractual rate. Deductibles - The amount a member must pay in a calendar or contract year for services. Members with POS plans must meet individual/family deductibles before coinsurance applies. For members of the Added Choice Triple Option, there are no deductibles in the traditional HMO tier for these members. Payments to satisfy Deductibles do not apply to the Out-of-Pocket Maximums. 12/14/2012 14

Note: Deductibles for all Added Choice products are separate in each tier, and they do not accumulate across tiers. In MultiChoice, members payments to satisfy their PPO tier deductible also apply to their HMO tier deductibles. However, payments towards the HMO tier or Out-of-Network tiers apply only toward those respective tiers. Coinsurance A percentage of the charges members must pay when they receive a covered service and have already met the terms of their deductible. Coinsurance will be 10% to 50%, depending on the plan option. For example, if the plan calls for the member to pay 20% of the total charge of the eligible service, Kaiser Permanente would pay 80% of the remaining charge, up to the UCR. Coinsurance applies to contracted, not billed, charges. Coinsurance %ages vary by tier, with highest cost sharing in the Out-of-Network tier. For Point of Service products (including Triple Option), only coinsurance payments apply to the applicable Out-of-Pocket Maximum accumulations. Copayment These policies also include copayments for office visits and prescriptions in the HMO and PPO tiers. Copayments do not apply to the medical deductibles. Copayments do not apply to the Deductibles or the Out-of-pocket maximums in any tier of POS plans. Out-of-Pocket Maximum Limits the total amount of coinsurance a member must pay over the course of a single year. For example, a deductible/coinsurance plan might have an out-of-pocket maximum of $2,000. Once a member has paid their deductible and that amount in coinsurance within a single year, Kaiser Permanente would pay 100 % of the cost of eligible services after that (except for applicable copayments, which are always required). The Out-of-Pocket Maximums in the Point-of-Service plans are separate in each tier, and do not cross-accumulate. Only coinsurance applies to the Out-of-Pocket Maximum accumulators. Some Point-of-Service benefits are covered only under Tier 1 (Kaiser Permanente). For all POS plans, these include: Inpatient mental health care Inpatient / outpatient alcohol and substance abuse Inpatient physical, occupational, and speech therapy Durable Medical Equipment (except prosthetic arms and legs) Organ transplants Oxygen Skilled nursing facility Emergency room care Ambulance Hearing exam Pre-certification Requirements for PPO and Out-of-Network services Pre-certification is the evaluation of treatments and services to assure that members care is appropriate and medically necessary for health care needs. 12/14/2012 15

The patient (or his/her doctor) must call SHPS (pronounced like ships ) for precertification at least 3 days prior to any scheduled hospital admission, unless admitted in an emergency. Pre-certification for emergency admissions must be obtained within 3 days following the admission. To obtain pre-certification, call 1-800-448-9776 (SHPS). Both the member and provider will receive written authorization confirming medical necessity. Prescriptions Members with Point-of-Service plans have two options to fill prescriptions: They may purchase prescriptions at any Kaiser Permanente pharmacy, provided the medications are on the KP formulary and medical guidelines are satisfied. Prescriptions may be written by providers outside Kaiser Permanente. Members usually pay a copayment. Mail order is also available through Kaiser Permanente s mail order service. Members may purchase any covered prescriptions through MedImpact, a network of nearly 60,000 pharmacies nationwide. The MedImpact network includes most major retail pharmacy chains in Colorado, including King Soopers, Albertsons, Safeway, Long s Drug, Wal*Mart, and Walgreens. Members pay a copayment. Members of MultiChoice POS plans may not purchase prescriptions through pharmacies other than Kaiser Permanente or MedImpact. Members of Added Choice plans may purchase prescriptions from pharmacies outside the MedImpact network. Members pay 50% coinsurance. Two-tier Added Choice pharmacy benefits may also require members to satisfy a deductible before the pharmacy coinsurance applies. The formulary is open for prescriptions purchased through MedImpact or Out-of- Network pharmacies. However, a Preferred Drug List determines members pharmacy copayments on MultiChoice Plans. Members copayments are either Preferred Generic, Preferred Brand, or Non-preferred Generic/Brand. For members of MultiChoice POS plans, certain self-administered injectible drugs are also covered when members purchase them through MedImpact pharmacies. Members pay 20% coinsurance for these prescriptions (up to $250 per fill). Neither Pharmacy coinsurance payments nor copayments apply to Medical deductibles or Out-of-Pocket Maximum accumulators. Please refer to the Physician Informational Document for POS Plans and forms for more information. Physician Information Document for POS Plans 12/14/2012 16

3.5.2.1 Member ID Cards for POS Denver/Boulder MultiChoice SM POS Plan Denver/Boulder Added Choice Deductible/Coinsurance Denver/Boulder Added Choice 2-Tier POS Plan 12/14/2012 17

Denver/Boulder Added Choice Triple Option Plan Southern Colorado MultiChoice SM POS Plan Southern Colorado Added Choice Deductible/Coinsurance 12/14/2012 18

Southern Colorado Added Choice 2-Tier POS Plan Southern Colorado Added Choice Triple Option Plan 3.5.3 PPO Products 12/14/2012 19

Traditional PPO Our traditional PPO product allows the member to take advantage of Kaiser Permanente s preferred provider network, Private Healthcare Systems (PHCS), with nearly 450,000 physicians and more than 4,000 facilities nationwide. Or if the member prefers, he can go to any other licensed practitioner or hospital he chooses. If the member gets care from within the preferred provider network, he will reduce costs through copayments for office visits (including diagnostic x-rays and lab work performed in the doctor s office), as well as lower deductibles and reduced coinsurance rates for other services. If the provider is outside the network, the member will pay higher deductibles & coinsurance, may be required to make his own financial arrangements, and may need to submit receipts or claims for reimbursement. Also, members are responsible for paying the difference between the amount billed & the amount that KP can reimburse. Prescriptions are covered and can be filled at any MedImpact network pharmacy, which includes pharmacies at Albertsons, King Soopers/City Market, Kmart, Longs Drugs, Medicine Shoppes, Safeway, Sam s Club, Target, Walgreens, and Walmart. The traditional PPO is available to large group members only. Out-of-Area PPO This plan is similar to our traditional PPO plan but is available to small group members only. This plan is available to members outside of Kaiser Permanente s service area who are not eligible for the HMO plan. PPO Plan with Health Savings Account (HSA) Option With this plan, the member can take advantage of Kaiser Permanente s Preferred Provider Network, Private Healthcare Systems (PHCS), or if the member prefers, he can go to any other licensed practitioner or hospital he chooses. In addition, the member can set up a Health Savings Account (HSA) which he can use to pay for qualified medical expenses, tax free. Kaiser Permanente has named Wells Fargo as a preferred partner, although members can have an HSA with any accredited financial institution. The PPO Plan with Health Savings Account (HSA) is available to large group members only. 3.5.3.1 PPO Member ID Cards Denver/Boulder PPO Plan 12/14/2012 20

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Denver/Boulder PPO Plan w/hs Option 12/14/2012 22

Southern Colorado PPO Plan 12/14/2012 23

Southern Colorado PPO Plan w/ HS Option 12/14/2012 24

PPO Plan 12/14/2012 25

Out of Area Plan 12/14/2012 26

3.5.4 Medicare Product Traditional HMO Medicare Product(s) Medicare Advantage - Kaiser Permanente has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer Medicare Advantage (MA) plans to Medicare beneficiaries. These plans are known as Senior Advantage. Kaiser Permanente offers five individual MA plans; Senior Advantage Core, Silver, Gold, Plus Choice, and our Special Needs Plan. The Special Needs Plan is for individuals with both Medicare and Medicaid. These plans provide comprehensive, high-quality healthcare, including Medicare Part D prescription-drug benefits. Based on the contract between Kaiser Permanente and CMS, Senior Advantage covers all Medicare benefits and more. Senior Advantage is available to Medicare beneficiaries who are eligible for Medicare Part A and are enrolled in Medicare Part B. In addition to our four individual plans, Kaiser Permanente offers Senior Advantage to the employer group market. Kaiser Permanente currently has over 60,000 Medicare Advantage members. The same referral guidelines that apply to our Kaiser Permanente commercial/non-medicare members should also apply to our Medicare Advantage members. Contract Financial Terms - Your contractual agreement describes the financial terms for all Kaiser Permanente members. The terms may define separate negotiated rates for the Medicare population. If a member has enrolled in our MA program DO NOT BILL MEDICARE, bill Kaiser Permanente. Providers are often reimbursed through the same mechanisms Medicare would use. For example, RBRVS, DMERC and DRG s. Your contract defines how you will be reimbursed for providing services. 12/14/2012 27

3.5.4.1 Member ID Cards Denver/Boulder Medicare Advantage Plan (Non Part D) Colorado Region Denver/Boulder/Longmont (Part D) 12/14/2012 28

3.5.5 Self-Funded (SF) Product Refer to www.providers.kp.org/cod to obtain information regarding the Self-Funded products. 3.5.5.1 Member ID Card Refer to www.providers.kp.org/cod for sample ID cards for Self-Funded Members. 3.5.6 Medicaid Product Kaiser Permanente no longer pays you for services you provide to these Medicaid clients (PCPP) as a result of a referral from a Kaiser Permanente provider. You will need to bill the State Medicaid program directly in order to receive reimbursement, and collect the appropriate copayment from the client. Kaiser Permanente continues to offer medical services to these Medicaid clients as a fee for service provider under the State s Primary Care Provider Program (PCPP). Our Medicaid provider number is 30478251. This number must be included as the referring physician on your claim. 3.5.6.1 Member ID Card Denver/Boulder Primary Care Physician Program (Medicaid) 3.6 Precertification Requirements 3.6.1 POS Precertification Requirements For all POS plans, pre-certification is required for the following services or treatments: o Comprehensive Rehabilitation Facility admissions related to services provided under an inpatient multidisciplinary rehabilitation program; o Inpatient Mental Health admissions and services o. Inpatient Chemical Dependency admissions and services 12/14/2012 29

o Inpatient admissions and services o Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for Mental Health o. Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for Chemical Dependency o Skilled Nursing Facility admissions o Outpatient Surgical Services o. Dental Anesthesia oartificial Intervetebral Disc Surgery o.interdiscal Electrothermal Annuoplasty (IDET) o.percutaneous Lumbar Discectomy o.vertebral Axial Decompression o.vertebroplasty o.orthognathic Surgery/TMJ o.reconstruction Surgery - Craniofacial Reconstruction - Breast Augmentation/Reduction/Implants -. Reconstruction (including all procedures by plastic surgeon) o.cosmetic Procedures - Blepharoplasty, Pitosis Repair - Septorhinoplasty - Sinus surgeries o.endoscopy (pill/capsule only) o.uppp and laser assisted UPPP o Varicose Vein Treatment/Sclerotherapy o.upper Airway Procedures - Pillar Palatal Implant - Somnoplasty (RF ablation) Outpatient Services o Pain Management -. Epidural Steroid Injection - Radiofrequency Ablation - Implantable Infusion Pump - Spinal Cord Stimulator o Sleep Studies (including home) o Experimental/Investigational Procedures and Drugs o Hyperbaric Oxyen Treatment o. Non-Emergent Air or Ground Ambulance Transport o Enhanced External Counterpulsation (EECP) o Plasma Pheresis for Multiple Sclerosis o Anodyne Therapy o Vagal Nerve Stimulation for Epilepsy o.imaging Service: MRI, MRA, CTA, PET, EBCT o Home Health, Home Infusion and Home Therapy o Outpatient Physical, Speech, Occupational, Respiratory - 20 visits per 12/14/2012 30

therapy per calendar year o.durable Medical Equipment o.autism Spectrum Disorder services 3.6.2 PPO Precertification Requirements For all PPO plans or tiers, precertification is required for the following services or treatments: o Comprehensive Rehabilitation Facility admissions related to services provided under an inpatient multidisciplinary rehabilitation program; o Inpatient Mental Health admissions and services o Inpatient Chemical Dependency admissions and services o Inpatient admissions and services, including admissions for transplants; o Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for Mental Health o Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for Chemical Dependency o Skilled Nursing Facility admissions o Outpatient Surgical Services o Dental Anesthesia o Artificial Intervetebral Disc Surgery o Interdiscal Electrothermal Annuoplasty (IDET) o. Percutaneous Lumbar Discectomy o Vertebral Axial Decompression o Vertebroplasty o Orthognathic Surgery/TMJ o Reconstruction Surgery -. Craniofacial Reconstruction -. Breast Augmentation/Reduction/Implants - Reconstruction (including all procedures by plastic surgeon) o. Cosmetic Procedures - Blepharoplasty, Pitosis Repair - Septorhinoplasty - Sinus surgeries o Endoscopy (pill/capsule only) o UPPP and laser assisted UPPP o Varicose Vein Treatment/Sclerotherapy o. Upper Airway Procedures - Pillar Palatal Implant - Somnoplasty (RF ablation) Outpatient Services o Pain Management 12/14/2012 31

- Epidural Steroid Injections - Radiofrequency Ablation - Implantable Infusion Pump - Spinal Cord Stimulator o Sleep Studies (including home) o Experimental/Investigational Procedures and Drugs o Hyperbaric Oxyen Treatment o Non-Emergent Air or Ground Ambulance Transport o Enhanced External Counterpulsation (EECP) o Plasma Pheresis for Multiple Sclerosis o Anodyne Therapy o Vagal Nerve Stimulation for Epilepsy o Imaging Service: MRI, MRA, CTA, PET, EBCT o Home Health, Home Infusion and Home Therapy o Outpatient Physical, Speech, Occupational, Respiratory - 20 visits per therapy per calendar year o Durable Medical Equipment o Oxygen o Autism Spectrum Disorder Services 3.6.3 KPICFor all KPIC plans or tiers, pre-certification is required for the following services or treatments: o Inpatient Rehabilitation Therapy admissions, services and programs o Inpatient Mental Health admissions and services o Inpatient Chemical Dependency admissions and services o Inpatient admissions and services o Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for Mental Health o Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for Chemical Dependency o Outpatient Surgical Services o Dental Anesthesia o Artificial Intervetebral Disc Surgery o Interdiscal Electrothermal Annuoplasty (IDET) o Percutaneous Lumbar Discectomy o Vertebral Axial Decompression o Vertebroplasty o Orthognathic Surgery/TMJ o Reconstruction Surgery - Craniofacial Reconstruction - Breast Augmentation/Reduction/Implants - Reconstruction (including all procedures by plastic surgeon) 12/14/2012 32

o Cosmetic Procedures - Blepharoplasty, Pitosis Repair - Septorhinoplasty - Sinus surgeries o Endoscopy (pill/capsule only) o UPPP and laser assisted UPPP o Varicose Vein Treatment/Sclerotherapy o Upper Airway Procedures - Pillar Palatal Implant - Somnoplasty (RF ablation) Outpatient Services o Pain Management - ESI - Radiofrequency Ablation - Implantable Infusion Pump - Spinal Cord Stimulator o Sleep Studies (including home) o Experimental/Investigational Procedures and Drugs o Hyperbaric Oxyen Treatment o Non-Emergent Air or Ground Ambulance Transport o Enhanced External Counterpulsation (EECP) o Plasma Pheresis for Multiple Sclerosis o Anodyne Therapy o Vagal Nerve Stimulation for Epilepsy o Imaging Service: MRI, MRA, CTA, PET, EBCT o Home Health, Home Infusion and Home Therapy o Outpatient Physical, Speech, Occupational, Respiratory - 20 visits per therapy per calendar year 3.7 Drug Benefits and Formulary Kaiser Permanente members who have a prescription drug may have their prescription filled at a Plan pharmacy at the applicable prescription drug copayment or coinsurance. In order to receive medications under the Prescription Drug Benefit, the prescription: 1. Must be prescribed by a Plan Physician, a physician to whom a member has been referred by a Plan Physician or a dentist (when prescribed for acute conditions). 12/14/2012 33

2. Must be purchased at Plan Pharmacies. Medications and accessories covered by the Prescription Drug benefit are: 1. Drugs for which a prescription is required by law. Plan pharmacies may substitute a generic equivalent for a brand-name drug unless prohibited by the Plan Physician. If a member requests a brand-name drug when a generic equivalent is the preferred product, the member may pay a cost differential dependent upon the members prescription drug benefit. If the brand-name drug is prescribed due to medical necessity, when the generic equivalent is on the formulary, the member pays only the brand-name copayment. 2. Insulin 3. Compounded medications are covered as long as they are on the compounding formulary for Denver Boulder members and plan Physicians may request compound medications through the medical exceptions process for Southern Colorado members. 4. Home glucose monitoring supplies, disposable syringes for the administration of insulin, glucose test strips, acetone test tablets and nitrite screening test strips for pediatric patient home use. Drug, Supplies and Supplements Exclusions: 1. Drugs for which a prescription is not required by law. 2. Disposable supplies for home use such as bandages, gauze, tape, antiseptics, dressing and ace-type bandages. 3. Drugs or injections for the treatment of sexual dysfunction, unless the member s group has purchased additional coverage. 4. Any package other than the dispensing pharmacy s standard packaging. 5. Replacement of prescript drugs for any reason, including but not limited to spilled, lost, damaged or stolen prescriptions. 6. Drugs for the treatment of infertility, unless the member s group has purchased additional coverage. 7. Drug used to shorten the duration of the common cold. 8. Drugs used to enhance athletic performance. 9. Drugs used in the treatment of weight control. 10. Drugs which are available over the counter and by prescription for the same strength. 11. Drugs and supplies for cosmetic purposes. 12. Vitamins and nutritional supplements that can be purchased without a prescription. 13. Non-prescription drugs, unless they are included in the drug formulary. 14. Drugs related to non-covered services. 15. Drugs for the promotion, prevention, or other treatment of hair loss or growth. Generic/Brand Prescription Benefit: 12/14/2012 34

To ensure cost effective therapy, generic equivalents are utilized when available and appropriate. Only approved generic equivalents approved by the FDA are used. Pharmacies may substitute a preferred generic drug for a prescribed name brand drug unless prohibited by the physician. If a member requests a brand name drug when a generic drug is the preferred agent, the member may pay a cost differential dependent upon the members prescription drug benefit. If the brand-name drug is prescribed due to medical necessity, when the generic equivalent is on the formulary, the member pays only the brand-name copayment. Dispensing Limitations: Kaiser Permanente may, in its sole discretion, establish quantity limits for specific prescription drugs. For example, when there is a shortage of a drug in the marketplace and the amount of available supplies is limited, we may reduce the quantity of drug dispensed Certain drugs that have a significant potential for waste will be provided for up to a 30-day supply only (e.g.: Avonex, Procrit). Therapeutic Interchange: Kaiser Permanente utilizes Therapeutic Interchange programs to promote rational, safe, and effective drug therapy. Prescribing provider approval is required before an exchange occurs. 3.7.1 Kaiser Permanente Participating Network Pharmacies: Kaiser Permanente Medical Care Program Colorado Region Pharmacy Hours of Operation / Pharmacy Contacts (updated 8/31/2012) Pharmacy Address - Phone - Fax Hours of Operation Arapahoe 5555 East Arapahoe Road 8:00 am - 6:00 pm Monday - Friday Centennial, CO 80122 8:00 am - 6:00 pm Saturday 9:00 am - 5:00 pm Sunday (303) 850-1570 FAX 850-2056 Aurora Centrepoint 14701 E. Exposition Avenue 8:00 am - 6:00 pm Monday - Friday Aurora, CO 80012 12/14/2012 35

(303) 614-7305 FAX 614-7303 CLOSED Weekends & Holidays Baseline 580 Mohawk Drive 8:00 am - 6:00 pm Monday - Friday Boulder, CO 80302 (303) 554-5015 FAX 554-5010 CLOSED Weekends & Holidays Brighton 859 4 th Avenue 8:30 am 5:30 pm Monday - Friday Brighton, CO 80601 (303) 835-5860 FAX (303) 835-5870 CLOSED Weekends & Holidays Castle Rock 4318 Trail Boss Drive 8:30 am 5:30 pm Monday - Friday Castle Rock, CO 80104 (303) 814-4160 FAX (303) 814-4170 CLOSED Weekends & Holidays Englewood 2955 South Broadway 8:00 am - 6:00 pm Monday - Friday Englewood, CO 80110 (303) 788-1043 FAX 788-1011 CLOSED Weekends & Holidays Evergreen 2942 Evergreen Parkway 8:30am-5:500 pm Monday-Friday Evergreen, CO 80439 (303) 318-3333 FAX 318-3336 CLOSED Weekends & Holidays Franklin 2045 Franklin Street 8:00 am - 6:00 pm Monday - Friday Denver, CO 80205 (303) 861-3239 FAX 861-3604 12/14/2012 36 8:00 am - 12:00 noon Saturday CLOSED Sundays & Holidays Hidden Lake 7701 Sheridan Boulevard 8:00 am - 6:00 pm Monday - Friday

Westminster, CO 80003 (303) 657-6707 FAX 657-6709 12/14/2012 37 CLOSED Weekends & Holidays Highlands Ranch 9285 Hepburn Street 8:00 am - 6:00 pm Monday - Friday Highlands Ranch, CO 80129 (720) 348-4603 FAX 348-4605 CLOSED Weekends & Holidays Home I.V. 16601 East CentreTech Pkwy 8:00 am - 4:45 pm Monday - Friday Aurora, CO 80011 (303) 344-7010 FAX 344-7048 CLOSED Weekends & Holidays Ken Caryl 7600 Shaffer Parkway 8:00 am - 6:00 pm Monday - Friday Littleton, CO 80127 (720) 922-5054 FAX 922-5055 CLOSED Sundays & Holidays Lakewood 8383 West Alameda Avenue 8:00 am - 6:00 pm Monday - Friday Lakewood, CO 80226 8:00 am - 4:00 pm Saturday 9:00 am - 4:00 pm Sunday (303) 239-7465 FAX 239-7405 CLOSED Holidays Longmont 2345 Bent Way 8:00 am - 6:00 pm Monday - Friday Longmont, CO 80501 (303) 678-3310 FAX 678-3302 CLOSED Weekends & Holidays Long Term Care 16601 East CentreTech Pkwy 8:00 am - 5:00 pm Monday - Friday Aurora, CO 80011 (303) 739-3513 FAX 344-7077 CLOSED Weekends & Holidays Oncology Franklin 8:30am - 5:15pm Monday - Friday 2045 Franklin Street

Denver, CO 80205 (303) 861-3300 FAX 861-3333 CLOSED Weekends & Holidays Parker 10168 S. Parkglenn Way 8:00 am 5:30 pm Monday - Friday Parker, CO 80138 CLOSED Weekends & Holiday (720) 842-5810 FAX (720) 842-5815 Rock Creek 280 Exempla Circle 8:00 am - 6:00 pm Monday - Friday Lafayette, CO 80026 (720) 536-7857 FAX 536-7855 CLOSED Weekends & Holidays Travel Clinic 2045 Franklin Street 8:00 am - 5:00 pm Monday - Friday Franklin Denver, CO 80205 (303) 861-3183 FAX 831-3756 CLOSED Weekends & Holidays Skyline 1375 East 20th Avenue 8:00 am - 6:00 pm Monday - Friday Denver, CO 80205 (303) 764-4670 FAX 764-4662 CLOSED Sundays & Holidays Smoky Hill 16290 East Quincy Avenue 8:00 am - 6:00 pm Monday - Friday Aurora, CO 80015 (303) 699-3826 FAX 699-3840 CLOSED Weekends & Holidays Southwest 5257 S. Wadsworth Blvd. 8:00 am - 6:00 pm Monday - Friday Littleton, CO 80123 12/14/2012 38

(303) 972-5018 FAX 972-5013 CLOSED Weekends & Holidays Westminster 11245 Huron Street 8:00 am - 6:00 pm Monday - Friday Westminster, CO 80234 8:00 am - 4:00 pm Saturday 9:00 am - 4:00 pm Sunday (303) 457-6082 FAX 457-6416 OPEN Holidays Wheatridge 4803 Ward Road 8:00 am - 6:00 pm Monday - Friday Wheatridge, CO 80033 (303) 467-5149 FAX 421-5066 CLOSED Weekends & Holidays PARC (Pharmacy Automated 16601 East Centretech Parkway 7:00 am - 5:30 pm Monday, Tuesday Refill Center) Aurora, CO 80011 7:00 am - 4:30 pm Wednesday - Friday Mail Order 7:00 am - 3:30 pm Sunday (303) 326-6770 FAX 326-6775 Holiday Schedule Varies - CLOSED Sa Southern Colorado Service Area: Kaiser Permanente uses a pharmacy benefit manager, MedImpact, to administer our prescription drug benefits in the Southern Colorado service area. In addition to the two Kaiser Permanente pharmacies listed below, members have various retail pharmacies available to them. For a detailed listing of participating pharmacies visit www.kp.org or call KP Member Services. Kaiser Permanente Medical Care Program Southern Colorado Pharmacy Hours of Operation / Pharmacy Contacts Pharmacy Address - Phone - Fax Hours of Operation 12/14/2012 39

Briargate Senior Health Center 4105 Briargate Parkway Colorado Springs, Co 80920-7842 (719) 282-2466 FAX (719) 282-2470 8:00 am 4:45 pm Monday Friday CLOSED Weekends & Holidays Pueblo North 3670 Parker Blvd 8:30 am 5:30 pm Monday Friday Pueblo, CO 81008-2207 (719) 595-5367 FAX (719) 595-5370 CLOSED Weekends & Holidays Mail Order Service: Kaiser Permanente Offers our members a mail order pharmacy services. The Kaiser Permanente Mail Order Pharmacy is available to all Kaiser Commercial members, Self Funded members and Medicare Part D members regardless of service area. Kaiser Permanente Mail Order Pharmacy 16601 E. Centretech Parkway Aurora, CO. 80011 Phone: (303) 326-6770 866-523-6059 3.72 Physician Access: Southern Colorado Only Kaiser Permanente offers a secure website for practitioners to access their patient s prescription drug histories. Our Physician Access website provides utilization reports and compliance reports for each patient, complete with drug refill histories over the past 12 months. The Web site address is: https://mp.medimpact.com/physicianportal To obtain your user access code, please contact Provider Relations at (719) 867-2131. 12/14/2012 40

3.8 Visiting Members Kaiser Permanente offers a Visiting Member Program to ensure that Members can receive a variety of health care services when temporarily visiting another Kaiser Permanente Region. Visiting Member benefits may not be the same as those they receive in their home service area and are subject to certain exclusions. Members are eligible to receive visiting Member benefits for up to 90 days. If they permanently move into another Region, they will be offered membership in the new Region. Visiting Members are directed to seek health care services at the nearest Kaiser Permanente Medical Office and contracted facilities/hospitals. If a PMG physician needs to refer a Visiting Member to a Participating Provider, you will receive an authorization letter explaining the start and end dates of the referral and a description of the authorized services. Claims should be submitted to the Denver/Boulder and Southern Colorado Kaiser Permanente claims department. 12/14/2012 41