Summary Of Benefits And Coverage: Kaiser Permanente, DHMO

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services:City and County of Denver DHMO 500Coverage Period: 01/01/2019 - 12/31/2019Coverage for: Individual/Family Plan Type: HMOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see www.kp.org/plandocuments or call 1855-249-5005 or TTY 711. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms see the Glossary. You can view the Glossary at www.HealthCare.gov/sbc-glossary/ or call 1-855-249-5005 or TTY 711 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible? 500 Individual / 1,500 FamilyAre there servicescovered before you meetyour deductible?Yes, preventive services,certain services with copays,prescription drugs and hospiceThis plan covers some items and services even if you haven’t yet met the deductible amount. Buta copayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at e-benefits/.Are there otherdeductibles for specificservices?No.You don’t have to meet deductibles for specific services, but see the chart starting on page 2 forother costs for services this plan covers.What is the out-of-pocketlimit for this plan? 3,000 Individual / 6,000 FamilyThe out-of-pocket limit is the most you could pay in a year for covered services. If you have otherfamily members in this plan, they have to meet their own out-of-pocket limits until the overallfamily out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Premiums, balanced-billedcharges and health care this plandoesn’t cover.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.Will you pay less if youuse a network provider?This plan uses a provider network. You will pay less if you use a provider in the plan’s network.Yes. See www.kp.org or call 1You will pay the most if you use an out-of-network provider, and you might receive a bill from a855-249-5005 or TTY 711 for a list provider for the difference between the provider’s charge and what your plan pays (balanceof plan providers.billing). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.Do you need a referral tosee a specialist?No.Generally, you must pay all of the costs from providers up to the deductible amount before thisplan begins to pay. If you have other family members on the plan, each family member must meettheir own individual deductible until the total amount of deductible expenses paid by all familymembers meets the overall family deductible.You can see the specialist you choose without a referral.1 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessIf you visit a healthcare provider’s officeor clinicIf you have a testSpecialist visitPreventive care/screening/immunizationNo ChargeNot CoveredDiagnostic test (x-ray, bloodwork)X-ray: 20% CoinsuranceLab: No ChargeNot CoveredImaging (CT/PET scans,MRIs)20% CoinsuranceNot CoveredGeneric drugsIf you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atwww.kp.orgIf you have outpatientsurgeryWhat You Will PayPlan ProviderNon-Plan Provider(You will pay the least) (You will pay the most) 30 Copay per visit; 20%Coinsurance for coveredNot Coveredservices received duringa visit. 50 Copay per visit; 20%Coinsurance for coveredNot Coveredservices received duringa visit.Preferred brand drugsNon-preferred brand drugsSpecialty drugsRetail: 20 Copay;Mail Order: 40 CopayRetail: 40 Copay;Mail Order: 80 CopayRetail: 60 Copay;Mail Order: 120 CopayCost share for generic,brand or non-preferreddrugs may applyNot CoveredNot CoveredNot CoveredNot CoveredLimitations, Exceptions, & Other ImportantInformationCopay not subject to deductible.Copay not subject to deductible.You may have to pay for services that aren’tpreventive. Ask your provider if the services youneed are preventive. Then check what your planwill pay for. Not subject to deductible.Diagnostic lab services: not subject to thedeductible except when provided in the outpatientdepartment of a hospital; 20% Coinsurance in theoutpatient department of a hospital.NoneSubject to formulary guidelines; Non-preferredbrand drugs must be authorized through the nonpreferred drug process. Federally mandated overthe counter items are covered with a prescriptionwhen filled at a Kaiser Permanente pharmacy. ForSouthern Colorado members: maintenancemedications must be filled at a Pharmacy in aKaiser Permanente medical office or throughKaiser Permanente mail order. Covers up to a 30day supply (retail prescription); 31-90 day supply(mail order prescription).Facility fee (e.g., ambulatory20% Coinsurancesurgery center)Not CoveredNonePhysician/surgeon feesNot CoveredNone20% CoinsuranceFor more information about limitations and exceptions, see the plan or policy document at www.kp.org/plandocuments or call 1-855-249-5005- or TTY 711.2 of 6

CommonMedical EventIf you need immediatemedical attentionIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesIf you are pregnantServices You May NeedWhat You Will PayPlan ProviderNon-Plan Provider(You will pay the least) (You will pay the most)Limitations, Exceptions, & Other ImportantInformationEmergency room care 200 Copay per visit 200 Copay per visitDoes not include imaging (CT/PET scans, MRIs);Emergency room services and imaging costswaived if admitted directly to the hospital as aninpatient. Copay not subject to deductible.Emergency medicaltransportation20% Coinsurance up to 50020% Coinsurance up to 500Not subject to deductible.Urgent care 75 Copay per visit; 20%Coinsurance for coveredservices received duringa visit. 75 Copay per visit; 20%Coinsurance for coveredservices received duringa visit.Non-Plan Providers: only covered if you are out ofthe service area. Copay not subject to deductible.Facility fee (e.g., hospitalroom)20% CoinsuranceNot CoveredNonePhysician/surgeon fees20% CoinsuranceNot CoveredNoneOutpatient services 30 Copay per visit; 20%Coinsurance for coveredservices received duringa visit.Not CoveredGroup visit 50% of individual visit copay. Copay notsubject to deductible.Inpatient services20% CoinsuranceNot CoveredNoneNot CoveredAfter confirmation of pregnancy, for the normalseries of regularly scheduled routine visits.Maternity care may include tests and servicesdescribed elsewhere in the SBC (i.e. ultrasound).Office visitsChildbirth/deliveryprofessional servicesChildbirth/delivery facilityservices20% CoinsuranceFor more information about limitations and exceptions, see the plan or policy document at www.kp.org/plandocuments or call 1-855-249-5005- or TTY 711.3 of 6

CommonMedical EventIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careServices You May NeedWhat You Will PayPlan ProviderNon-Plan Provider(You will pay the least) (You will pay the most)Home health care20% CoinsuranceNot CoveredRehabilitation servicesInpatient services: 20%CoinsuranceOutpatient services: 30Copay per visitNot CoveredHabilitation services 30 Copay per visitNot CoveredSkilled nursing care20% CoinsuranceNot CoveredDurable medical equipment20% CoinsuranceNot CoveredHospice servicesNo Charge 30 Copay per visit; 20%Coinsurance for coveredservices received during avisit.Not CoveredNot CoveredNot CoveredChildren’s eye examChildren’s glassesChildren’s dental check-upLimitations, Exceptions, & Other ImportantInformationLimited to less than 8 hours per day and 28 hoursper week.Inpatient: Multi-disciplinary facility limited to 60days per condition per year.Outpatient: Outpatient visits limited to 20 visits pertherapy per year (autism spectrum disorders arenot subject to the visit limit). Copay not subject todeductible.Outpatient visits limited to 20 visits per therapy peryear (autism spectrum disorders are not subject tothe visit limit). Copay not subject to deductible.Limited to 100 days per year.Coverage is limited to items on our DME formulary.Prosthetic arms and legs at 20% Coinsurance. Notsubject to deductible.Not subject to deductible.Not CoveredFor services with an ophthalmologist see“Specialist visit”. Copay not subject to deductible.Not CoveredNot CoveredNoneNoneExcluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Long Term Care/Custodial Nursing Home Care Routine Foot Care Non-emergency care when traveling outside the U.S. Cosmetic Surgery Weight Loss Programs Routine Dental Services Hearing aids with limits (Adults)Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Infertility treatment Chiropractic care Private-Duty Nursing Bariatric surgery Hearing aids with limits Routine eye careFor more information about limitations and exceptions, see the plan or policy document at www.kp.org/plandocuments or call 1-855-249-5005- or TTY 711.4 of 6

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: The plan at 1-855-249-5005 or TTY 711. You may also contact your state insurance department, the U.S. Department of Labor, Employee BenefitsSecurity Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 orwww.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace.For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: The plan at 1-855-249-5005 or TTY 711; Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform; or the Colorado Division of Insurance, Consumer Affairs Section, at 1560 Broadway, Ste 850, Denver, CO 80202 or call: 303-8947490 (instate, toll-free: 800-930-3745), or email: insurance@dora.state.co.us.Does this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.Does this plan meet the Minimum Value Standard

500 500 deductible. Urgent care 75 Copay per visit; 20% Coinsurance for covered services received during a visit. 75 Copay per visit; 20% Coinsurance for covered services received during a visit. Non-Plan Providers: only covered if you are out of the service area. Cop