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• This benefit chart is a summary only. It does not fully describe your benefit coverage. For details on your benefit coverage, please refer to Kaiser Permanente Foundation Health Plan, Inc., Evidence of Coverage. The Evidence of Coverage is the binding document between Health Plan and its members.
• A Health Plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Health Plan physician. You must receive the services and supplies at a Health Plan facility or skilled nursing facility inside our Service area, except where specifically noted to the contrary in the Evidence of Coverage.
• For details on the benefit and claims review and adjudication procedures, please refer to Kaiser Permanente Health Plan’s Evidence of Coverage or contact Kaiser Permanente Membership Services at 1(800) 464-4000.

Kaiser Permanente Summary of Benefits for Early Retirees

Service	Co-payment
Outpatient Care
Primary care visits	$5 per visit
Specialty care visits	$5 per visit
Same-day outpatient surgery	$5 per procedure
Allergy testing	$5 per visit
Allergy injections	No Charge
Respiratory therapy visits	$5 per visit
Routine physical exams	$5 per visit
Gynecological visits	$5 per visit
Scheduled prenatal care and first postpartum visit	$5 per visit
Emergency Department visits	$5 per visit (waived if admitted directly to the hospital)
Blood, blood products, and their administration 2	$5 per visit
Hospital Inpatient Care
Room and board and critical care units	No charge
Obstetrical care and delivery, including cesarean section	No charge
Physician, surgeon, and surgical services	No charge
General and special nursing care	No charge
Anesthesia, prescribed drugs, and medical supplies	No charge
Blood, blood products, and their administration	No charge
Respiratory therapy	No charge
Ambulance Co-payment
Ambulance services and supplies	No charge
Prescription Drug Coverage
Most covered outpatient items in accord with our drug for our drug formulary when obtained at Plan Pharmacies:
Generic Items	$0 for up to a 100-day supply
Brand name Items	$10 for up to a 100-day supply
Chemical Dependency Services
Inpatient detoxification	No charge
Outpatient individual therapy visits	$5 per visit
Outpatient group therapy visits	$2 per visit
Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five year period)	$100 per admission
Dialysis Care
Inpatient care	No charge
Physician office visits	$5 per visit
Dialysis treatment visits	$5 per visit
Durable Medical Equipment
Durable medical equipment	No charge
Family Planning
All services related to family planning	$5 per visit
Health Education
Education for specific conditions: Individual visits Group visits	$5 per visit No charge
Education not addressed to a specific condition	Charges vary
Health education publications	No charge
Hearing
Hearing tests	$5 per visit
Home Health Care
Covered home health care, including physical, occupational, and speech therapy	No charge
Hospice Care
Covered hospice care	No charge
Imaging, Lab Tests, and Special Procedures
Imaging, lab tests, special procedures, and ultraviolet light treatment visits	No charge
Infertility Services
Office visits and outpatient surgery	$5 per visit
Outpatient surgery	$5 per procedure
Outpatient lab tests, imaging, and special procedures	No charge
Hospital inpatient care	No charge
Inpatient lab tests, imaging, and special procedures	No charge
Mental Health Services
Inpatient psychiatric care and hospital alternative services	No charge
Outpatient visit	$5 per visit
Individual visit	$5 per visit
Group visit	$2 per visit
Ostomy and Urological Supplies
Ostomy and urological supplies	No charge
Out-of-Plan Emergency Care
Covered services	Any Co-payment that would apply had you received the services from Plan Providers
Physical, Occupational, and Speech Therapy and Multidisciplinary Rehabilitation
Physical, occupational, and speech therapy: Inpatient services Outpatient visits	No charge $5 per visit
Multidisciplinary rehabilitation: Inpatient Outpatient	No charge $5 per day
Prosthetic and Orthotic Devices
Covered devices	No charge
Reconstructive Surgery
Inpatient care	No charge
Office visits	$5 per visit
Same-day outpatient surgery	$5 per procedure
Skilled Nursing Facility Care
Care in a Skilled Nursing Facility (up to 100 days per benefit period)	No charge
Transplants
Inpatient care	No charge
Physician office visits	$5 per visit
Vision
Eye refraction exams to determine the need for vision correction and to provide a prescription for eyeglasses	$5 per visit
Regular plastic eyeglass lenses every 24 months	$100 allowance*
An eyeglass frame every 24 months
Medically necessary contact lenses	No charge
*An allowance is the total expense of an item that is covered. If the cost of the item you select exceeds the allowance, you will pay the difference.
Annual Co-payment Limit
There are limits to the total amount of Co-payments you must pay in a calendar year for certain services covered under this EOC. Those limits are: One Member Subscriber and all his or her Dependents	$1,500 $3,000
Co-payments for only the following covered services apply toward these limits: Ambulance services Home health care Hospital care Imaging, lab tests, and special procedures Out-of-Plan emergency care Physical, occupational, and speech therapy and multidisciplinary rehabilitation Professional services

Chiropractic
Chiropractic benefits are offered through American Specialty Health Plans of California. The co-payment for each visit is $5 for up to 30 visits per year. Please call the Member Services department for a Chiropractic Provider Directory to find a Chiropractor near you at (800) 464-4000. If you have questions about your chiropractic benefits, call ASH Plans Member Services at (800) 678-9133.