A BETTER WAY WASHINGTON 2017 - Kaiser …...the high-quality integrated care that sets Kaiser...

60605808_NW-WA_5/17

All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR 97232.

For Washington groups with 51 or more employeesProduct portfolio

WASHINGTON

2017A BETTER WAYto take care of business

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TRADITIONAL PLANSOur sensible approach to health care has benefited individuals and families in the Northwest for more than 70 years. Employees will pay simple copayments for most services when they come in for care. Most preventive services are provided at no additional charge. There are no claim forms or deductibles to worry about. DEDUCTIBLE PLANSTo help balance the needs of businesses and their employees, we offer multiple plans with various copayments, coinsurance levels, deductibles, and out-of-pocket maximums. Employees will pay simple copayments for most outpatient visits and preventive services are provided at no additional charge. Employers can choose the plans that best meet their needs, whether the overall goal is to keep employee costs down or reduce premiums. These plans may also be paired with a Kaiser Permanente health reimbursement arrangement (HRA) or flexible spending account (FSA).

ADDED CHOICE® PLANSWould you like to give your employees the opportunity to keep their current doctor or the option of seeing any licensed provider for covered services — at any time? Do you have employees who travel for extended periods of time and need access to routine care? Kaiser Permanente offers the option to see any licensed provider across the nation for covered services — along with exclusive access to our Select Providers or Select Facilities. Added Choice members have a dedicated Member Services phone line to ensure a high level of service and support.

• Go to a Select Provider or Select Facility and receive quality integrated care at an affordable price.

• Go to a Select Provider, Select Facility, or PPO provider and receive preventive care at no additional charge.

• Go to a PPO provider or facility anywhere in the nation and receive covered services with higher copayments and coinsurance. Kaiser Permanente has partnered with First Choice Health to provide an extensive PPO network for our members. Visit kp.org/addedchoice for a list of all PPO providers.

• Go to any other non-participating provider or facility nationwide for covered services. Since these providers are not contracted with us, they may require payment in advance of or at the time services are rendered. They may also be unwilling to bill us on the member’s behalf. We’ll reimburse charges for covered services paid

by members at the allowed amount* (less applicable coinsurance) once they’ve satisfied their deductible.

Added Choice may also be paired with a Kaiser Permanente HRA or FSA. With Added Choice, employees choose their own best balance among cost, choice, and coverage!

HSA-QUALIFIED HIGH DEDUCTIBLE PLANSWe combine the cost savings of a high deductible health plan with a collaborative approach to care that helps keep employees healthier and more productive — at work and at home. Helping to prevent issues before they start, most preventive services are provided at no additional charge and are not subject to the deductible. HSA-qualified plans may be paired with a Kaiser Permanente HSA, HRA, or FSA.

KAISER PERMANENTE’S INTEGRATED CONSUMER-DIRECTED PLAN OFFERINGSConsumer engagement meets Kaiser Permanente’s high-quality careWith consumer-directed health care — HRAs, HSAs, and FSAs — you can have workers who are more fully engaged in maintaining their health. Kaiser Permanente has been guiding our members toward healthier behavior for more than six decades. Now our integrated offering blends one of the nation’s most experienced consumer-directed health care administrators with the high-quality integrated care that sets Kaiser Permanente apart.

You pick the plan design that works for you from a wide range of deductibles, copays, and coinsurance. Your employees will be encouraged to participate in managing their health — not only from a financial standpoint due to plan design, but because that’s how we deliver care. With Kaiser Permanente’s integrated solution, your employees can access their plan information — and their health information — right from their desktop or mobile device.

You get:• Comprehensive administrative support.• Multiple account-funding options.• Easy transition to a Kaiser Permanente consumer-

directed plan.• Online enrollment and eligibility management.• A customizable employee portal.

PLAN OVERVIEWS

* Allowed amount: see your Evidence of Coverage (EOC) for complete details.

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• Reports and notifications delivered to you automatically.

Your employees get:• A single Kaiser Permanente health payment card that

works for HRAs, individual health savings accounts (HSAs), and FSAs as well as stacked FSA/HRA accounts.

• Ability to access all accounts, manage their personal health information, and file financial account claims just by signing on to kp.org.

• Real-time transaction information.• Live phone support.

Consumer-directed health care optionsTake advantage of Kaiser Permanente’s integrated consumer-directed health care offerings by choosing the health plan and financial arrangement that works for you.

All Kaiser Permanente deductible plans may be paired with HRAs, FSAs, and stacked FSA/HRA accounts.

Kaiser Permanente’s HSA-qualified high deductible health plans may be paired with any of the above, in addition to HSAs.

MEDICAL PLANFINANCIAL ACCOUNT1

HRA HSA FSA Stacked FSA/HRA Limited Purpose HRA3

DEDUCTIBLE PLAN NA2

HSA-QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN (HDHP)

ADDED CHOICE PLAN NA2

HSA-QUALIFIED ADDED CHOICE PLAN

TRADITIONAL PLAN NA NA2 NA NA1All financial account options above are subject to IRS 213d rules for reimbursement and are supported by a Kaiser Permanente Health Payment Card.2HSA may only be paired with an HSA-qualified plan per U.S. Treasury guidelines. Additional financial accounts may affect HSA tax-exempt status.3Limited purpose HRA is available for dental, vision hardware, or pharmacy services.

Additional financial account options are available. Please contact your producer or sales associate for more information on Kaiser Permanente’s plan designs for groups with 51 or more employees.

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PLAN HIGHLIGHTS FOR TRADITIONAL COPAYMENT PLANS

PLAN OPTIONS Plan B Plan C Plan D Plan E Plan F Plan G Plan H Plan J Plan K

BENEFIT/FEATURE*

Member pays

Member pays

Member pays

Member pays

Member pays

Member pays

Member pays

Member pays

Member pays

DEDUCTIBLE PER MEMBER

$0 $0 $0 $0 $0 $0 $0 $0 $0

OFFICE VISITS — PRIMARY CARE

$10 $10 $15 $15 $20 $20 $25 $30 $35

OFFICE VISITS — SPECIALTY CARE

$20 $20 $25 $25 $30 $30 $35 $40 $45

OFFICE VISITS — URGENT CARE

$30 $30 $35 $35 $40 $40 $45 $50 $60

OFFICE VISITS — PREVENTIVE CARE

$0 $0 $0 $0 $0 $0 $0 $0 $0

INPATIENT HOSPITAL CARE

$50 copayment per day, up to $250 per admission



$200 copayment per day, up to $1,000 per admission


$200 copayment per day, up to $1,000 per admission

$500 per admission

$750 per admission

$800 per admission

EMERGENCY CARE

$200 $200 $200 $200 $200 $200 $200 $200 $200

OUTPATIENT SURGERY

$20 $50 $20 $50 $50 $50 $75 $100 $150

LAB VISITS $10 $10 $15 $15 $20 $20 $25 $30 $35

X-RAYS AND SPECIAL DIAGNOSTIC PROCEDURES

$10 $10 $15 $15 $20 $20 $25 $30 $35

CT, MRI, AND PET SCANS

$50 $50 $50 $50 $50 $50 $50 $50 $50

OUT-OF-POCKET MAXIMUM PER MEMBER

$600 $600 $600 $1,500 $1,000 $1,500 $1,500 $2,000 $3,000

OUT-OF-POCKET MAXIMUM PER FAMILY

$1,200 $1,200 $1,200 $3,000 $2,000 $3,000 $3,000 $4,000 $6,000

These plans are subject to exclusions and limitations. A complete list of the exclusions and limitations is included in the Evidence of Coverage (EOC). To obtain a copy of the EOC, contact the Client Services Unit at 1-866-246-3613 (toll free).* These plans include limited coverage for dependent children outside the Kaiser Foundation Health Plan of the Northwest service area.

For covered services, the member pays 20 percent of the actual fee. Services are limited to 10 office visits, 10 diagnostic labs or X-rays, and 10 prescription drug fills.

For specific plan information, see the following form: EWLGTRAD0117

All of the following are non-grandfathered plans:

BWLGTRADC16B0117 BWLGTRADC16C0117 BWLGTRADC16D0117 BWLGTRAD C16E0117 BWLGTRADC16F0117

BWLGTRADC16G0117 BWLGTRADC16H0117 BWLGTRADC16J0117 BWLGTRADC16K0117

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SUPPLEMENTAL BENEFITSBelow are just a few of many options available with a medical plan. Contact your sales executive or account manager for more information.

Outpatient prescription drugsThe Kaiser Permanente formulary applies to all plans. Members get up to a 30-day supply for each copayment (up to a 90-day supply of maintenance drugs for two copayments when our Mail-Delivery Pharmacy is used). 1 All of these plans are Medicare Part D creditable. View our formulary at kp.org/formulary.

Options Member pays

$10/$20/$40/$150 $10 for generic, $20 for preferred brand-name drug, $40 for non-preferred brand-name drug, $150 for specialty drugs

$10/$20/$40 $10 for generic, $20 for preferred brand-name drug, $40 for non-preferred brand-name drug

$10/$30/50%–$100/50%–$150 $10 for generic, $30 for preferred brand-name drug, 50% up to $100 for non-preferred brand-name drug, 50% up to $150 for specialty drugs

$10/$30/50%–$100 $10 for generic, $30 for preferred brand-name drug, 50% up to $100 for non-preferred brand-name drug


$15/$30/50%–$200 $15 for generic, $30 for preferred brand-name drug, 50% up to $200 for non-preferred brand-name drug





Note: Prescription drug cost shares apply to the medical out-of-pocket maximum.1Specialty drugs are provided at one copay (or one maximum) for a 30-day supply.

Alternative careSelf-referred care without prior authorization is available for naturopathic care, chiropractic, acupuncture, and massage therapy from The CHP Group network providers in our service area. Visit chpgroup.com for a list of providers. Annual benefit maximums of $500, $1,000 or $1,500 for massage therapy and naturopathic care. Acupuncture services are not subject to the annual benefit maximum. Annual limit of 12 massage therapy visits and 12 acupuncture visits per calendar year. Office visit copayment will match the cost of the specialty office visit copayment.

Vision hardware2

Hardware options Member pays

12-month allowance For members 19 and above:Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or $500 For members 18 and under:No charge for one pair of frames and lenses or contacts every 12 months.

24-month allowance For members 19 and above:Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months. Allowance options: $100, $150, $200, $250, $300, $400, or $500For members 18 and under:No charge for one pair of frames and lenses or contacts every 12 months.

Hearing aids One hearing aid per ear per three-year period up to $250, $500, $1,000, $1,500 allowance.

2Member payments for supplemental benefits do not apply to the medical out-of-pocket maximum.

Note: These supplemental benefits are not available with Senior Advantage plans.

SUPPLEMENTAL BENEFIT OPTIONS FOR TRADITIONAL AND DEDUCTIBLE PLANS

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PLAN HIGHLIGHTS FOR DEDUCTIBLE PLANS

PLAN 150/10% TR

PLAN 150/10%

PLAN 150/20%

PLAN 250/10% TR

PLAN 250/10%

PLAN 250/20% TR

PLAN 250/20%

PLAN 500/10% TR

PLAN 500/10%

PLAN 500/20%


$150 $150 $150 $250 $250 $250 $250 $500 $500 $500

DEDUCTIBLE PER FAMILY

$450 $450 $450 $750 $750 $750 $750 $1,500 $1,500 $1,500


$1,150 $1,650 $1,650 $1,250 $2,250 $1,750 $2,250 $2,000 $3,000 $3,000


$3,450 $4,950 $4,950 $3,750 $6,750 $5,250 $6,750 $6,000 $9,000 $9,000

BENEFITS1 Member pays


$10* $10* $15* $15* $15* $15* $15* $20* $20* $20*


$30* $30* $35* $35* $35* $35* $35* $40* $40* $40*


$0* $0* $0* $0* $0* $0* $0* $0* $0* $0*

OFFICE VISITS — PRENATAL CARE

$0* $0* $0* $0* $0* $0* $0* $0* $0* $0*


$20* $20* $25* $25* $25* $25* $25* $30* $30* $30*

ROUTINE EYE EXAMS

$10* $10* $15* $15* $15* $15* $15* $20* $20* $20*

OUTPATIENT SURGERY

10% coinsurance after deductible










LAB VISITS $10* $10* $15* $15* $15* $15* $15* $20* $20* $20*


$10* $10* $15* $15* $15* $15* $15* $20* $20* $20*

CT, MRI, AND PET SCANS

$100* $100* $100* $100* $100* $100* $100* $100* $100* $100*

EMERGENCY CARE






















1These plans include limited coverage for dependent children outside the Kaiser Foundation Health Plan of the Northwest service area. For covered services, the member pays 20 percent of the actual fee. Services are limited to 10 office visits, 10 diagnostic labs or X-rays, and 10 prescription drug fills.

*Deductible does not apply.

For standard plans, the following services are not subject to deductible: most outpatient office visits; labs, X-rays, and special diagnostic procedures; urgent care; and supplemental options such as alternative care, adult hearing aids, prescription drugs, physical, speech, and occupational therapies, and vision hardware (if purchased). The deductible and most copayments and coinsurance apply to the out-of-pocket maximum. Visit kp.org/deductibleplans for more information on how our deductible plans work.

Most of our deductible plans can be paired with an Added Choice plan, and many are included in our multi-plan bundles on page 8. Deductible plans with “TR” in the name are tailored to provide additional pairing combinations within the product pairing guidelines for Added Choice.

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PLAN 750/20% TR

PLAN 750/20%

PLAN 1000/20%

PLAN 1500/20%

PLAN 2000/20% TR

PLAN 2000/30%

PLAN 2500/20%

PLAN 3000/20% TR

PLAN 3000/20%

PLAN 3500/20%

PLAN 5000/20%

$750 $750 $1,000 $1,500 $2,000 $2,000 $2,500 $3,000 $3,000 $3,500 $5,000

$2,250 $2,250 $3,000 $4,500 $6,000 $6,000 $7,500 $9,000 $9,000 $10,500 $12,700

$2,250 $3,250 $4,000 $5,000 $5,000 $6,850 $5,000 $5,000 $6,850 $6,850 $6,850

$6,750 $9,750 $12,000 $10,000 $10,000 $13,700 $10,000 $10,000 $13,700 $13,700 $13,700

Member pays

$20* $20* $25* $25* $25* $30* $25* $30* $30* $30* $30*

$40* $40* $45* $45* $45* $50* $45* $50* $50* $50* $50*

$0* $0* $0* $0* $0* $0* $0* $0* $0* $0* $0*

$0* $0* $0* $0* $0* $0* $0* $0* $0* $0* $0*

$30* $30* $35* $35* $35* $40* $35* $40* $40* $40* $40*

$20* $20* $25* $25* $25* $30* $25* $30* $30* $30* $30*












$20* $20* $25* $25* $25* $30* $25* $30* $30* $30* $30*

$20* $20* $25* $25* $25* $30* $25* $30* $30* $30* $30*

$100* $100* $100* $100* $100* $100* $100* $100* $100* $100* $100*























1These plans include limited coverage for dependent children outside the Kaiser Foundation Health Plan of the Northwest service area. For covered services, the member pays 20 percent of the actual fee. Services are limited to 10 office visits, 10 diagnostic labs or X-rays, and 10 prescription drug fills.

*Deductible does not apply.

For specific plan information, see the following form: EWLGDED0116. All of the following are non-grandfathered plans:

BWLGDEDAC160117 BWLGDEDBC160117 BWLGDEDCC160117

BWLGDED1C160117 BWLGDED2C160117 BWLGDED3C160117

BWLGDED4C160117 BWLGDED5C160117

BWLGDED6C160117 BWLGDEDDC160117

BUNDLED DEDUCTIBLE AND ADDED CHOICE PLANS

PLAN 250 DD

DEDUCTIBLE PLAN 250 - 20% TR ADDED CHOICE DD

DEDUCTIBLE (PER CALENDAR YEAR)

$250 per member,$750 per family

INDIVIDUAL/FAMILY

Tier 11 $250 / $750

Tier 22 $500 / $1,500

Tier 33 $750 / $2,250

OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)

$1,750 per member,$5,250 per family

Tier 11 $1,750 / $5,250

Tier 22 $3,000 / $9,000

Tier 33 $4,000 / $12,000


$15*

Tier 11 $20

Tier 22 $30

Tier 33 45%†


$35*

Tier 11 $40

Tier 22 $50

Tier 33 45%†

OFFICE VISITS FOR PREVENTIVE AND WELL-CHILD CARE AND PREVENTIVE SERVICES

$0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†


$0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†


$25*

Tier 11 $30

Tier 22 $40

Tier 33 45%†

ROUTINE EYE EXAMS $15*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

OUTPATIENT SURGERY 20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 45%†

LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES

$15 per visit*

Tier 11 $20 / $100

Tier 22 $30 / 30%†

Tier 33 45%†

CT, MRI, AND PET SCANS $100*

Tier 11 $100

Tier 22 30%†

Tier 33 45%†

EMERGENCY CARE 20% of charges $200


20% of charges

INPATIENT COPAY PER ADMISSION

Tier 11 20%†

Tier 22 30%†

Tier 33 45%†

PLAN 500 DE

DEDUCTIBLE PLAN 500 - 20% ADDED CHOICE DE

$500 per member,$1,500 per family

INDIVIDUAL/FAMILY

Tier 11 $500 / $1,500

Tier 22 $1,000 / $3,000

Tier 33 $1,500 / $4,500


Tier 11 $3,000 / $6,000

Tier 22 $4,750 / $9,500

Tier 33 $6,000 / $12,000

$20*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

$40*

Tier 11 $40

Tier 22 $50

Tier 33 45%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†

$30*

Tier 11 $30

Tier 22 $40

Tier 33 45%†

$20*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 45%†

$20 per visit*

Tier 11 $20 / $100

Tier 22 $30 / 30%†

Tier 33 45%†

$100*

Tier 11 $100

Tier 22 30%†

Tier 33 45%†

20% of charges $200

20% of charges


Tier 11 20%†

Tier 22 30%†

Tier 33 45%†

*Deductible does not apply.† Deductible applies.See footnotes in Deductible plans and Added Choice plans sections of this booklet for restrictions and more information.

PLAN 750 DP

DEDUCTIBLE PLAN 750 - 20% TR ADDED CHOICE DP


INDIVIDUAL/FAMILY

Tier 11 $750 / $2,250

Tier 22 $1,500 / $4,500

Tier 33 $2,250 / $6,750


Tier 11 $2,250 / $4,500

Tier 22 $4,500 / $9,000

Tier 33 $6,000 / $12,000

$20*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

$40*

Tier 11 $45

Tier 22 $55

Tier 33 40%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$30*

Tier 11 $35

Tier 22 $45

Tier 33 40%†

$20*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 40%†

$20 per visit*

Tier 11 $25 / $100

Tier 22 $35 / 30%†

Tier 33 40%†

$100*

Tier 11 $100

Tier 22 30%†

Tier 33 40%†

20% of charges $200

20% of charges


Tier 11 20%†

Tier 22 30%†

Tier 33 40%†

PLAN 1000 DN

DEDUCTIBLE PLAN 1000 - 20% ADDED CHOICE DN


INDIVIDUAL/FAMILY

Tier 11 $1,000 / $3,000

Tier 22 $2,000 / $6,000

Tier 33 $3,000 / $9,000


Tier 11 $4,000 / $8,000

Tier 22 $6,000 / $12,000

Tier 33 $7,500 / $15,000

$25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

$45*

Tier 11 $45

Tier 22 $55

Tier 33 40%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$35*

Tier 11 $35

Tier 22 $45

Tier 33 40%†

$25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 40%†

$25 per visit*

Tier 11 $25 / $100

Tier 22 $35 / 30%†

Tier 33 40%†

$100*

Tier 11 $100

Tier 22 30%†

Tier 33 40%†

20% of charges $200

20% of charges


Tier 11 20%†

Tier 22 30%†

Tier 33 40%†

PLAN 1500DX

DEDUCTIBLE PLAN 1500 - 20% ADDED CHOICE DX


INDIVIDUAL/FAMILY

Tier 11 $1,500 / $4,500

Tier 22 $3,000 / $9,000

Tier 33 $4,500 / $13,500


Tier 11 $5,000 / $10,000

Tier 22 $6,850 / $13,700

Tier 33 $8,400 / $16,800

$25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

$45*

Tier 11 $45

Tier 22 $55

Tier 33 40%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$35*

Tier 11 $35

Tier 22 $45

Tier 33 40%†

$25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 40%†

$25 per visit*

Tier 11 $25 / $100

Tier 22 $35 / 30%†

Tier 33 40%†

$100*

Tier 11 $100

Tier 22 30%†

Tier 33 40%†

20% of charges $200

20% of charges


Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


10


PLAN 250/500 DD

DEDUCTIBLE PLAN 250 - 20% TR

DEDUCTIBLE PLAN 500 - 20% ADDED CHOICE DD


$250 per member,$750 per family


INDIVIDUAL/FAMILY

Tier 11 $250 / $750

Tier 22 $500 / $1,500

Tier 33 $750 / $2,250




Tier 11 $1,750 / $5,250

Tier 22 $3,000 / $9,000

Tier 33 $4,000 / $12,000

OFFICE VISITS — PRIMARY CARE $15* $20*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

OFFICE VISITS — URGENT CARE $35* $40*

Tier 11 $40

Tier 22 $50

Tier 33 45%†


$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†

OFFICE VISITS — PRENATAL CARE $0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†

OFFICE VISITS — SPECIALTY CARE $25* $30*

Tier 11 $30

Tier 22 $40

Tier 33 45%†

ROUTINE EYE EXAMS $15* $20*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

OUTPATIENT SURGERY 20% of charges 20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 45%†


$15 per visit* $20 per visit*

Tier 11 $20 / $100

Tier 22 $30 / 30%†

Tier 33 45%†

CT, MRI, AND PET SCANS $100* $100*

Tier 11 $100

Tier 22 30%†

Tier 33 45%†

EMERGENCY CARE 20% of charges 20% of charges $200

INPATIENT HOSPITAL CARE 20% of charges 20% of charges


Tier 11 20%†

Tier 22 30%†

Tier 33 45%†


11

PLAN 500/1000 DE

DEDUCTIBLE PLAN 500 - 20%

DEDUCTIBLE PLAN 1000 - 20% ADDED CHOICE DE



INDIVIDUAL/FAMILY

Tier 11 $500 / $1,500

Tier 22 $1,000 / $3,000

Tier 33 $1,500 / $4,500



Tier 11 $3,000 / $6,000

Tier 22 $4,750 / $9,500

Tier 33 $6,000 / $12,000

$20* $25*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

$40* $45*

Tier 11 $40

Tier 22 $50

Tier 33 45%†

$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†

$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 45%†

$30* $35*

Tier 11 $30

Tier 22 $40

Tier 33 45%†

$20* $25*

Tier 11 $20

Tier 22 $30

Tier 33 45%†

20% of charges 20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


Tier 11 $20 / $100

Tier 22 $30 / 30%†

Tier 33 45%†

$100* $100*

Tier 11 $100

Tier 22 30%†

Tier 33 45%†

20% of charges 20% of charges $200



Tier 11 20%†

Tier 22 30%†

Tier 33 45%†

PLAN 750/1500 DP

DEDUCTIBLE PLAN 750 - 20% TR

DEDUCTIBLE PLAN 1500 - 20% ADDED CHOICE DP



INDIVIDUAL/FAMILY

Tier 11 $750 / $2,250

Tier 22 $1,500 / $4,500

Tier 33 $2,250 / $6,750



Tier 11 $2,250 / $4,500

Tier 22 $4,500 / $9,000

Tier 33 $6,000 / $12,000

$20* $25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

$40* $45*

Tier 11 $45

Tier 22 $55

Tier 33 40%†

$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$30* $35*

Tier 11 $35

Tier 22 $45

Tier 33 40%†

$20* $25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†


Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


Tier 11 $25 / $100

Tier 22 $35 / 30%†

Tier 33 40%†

$100* $100*

Tier 11 $100

Tier 22 30%†

Tier 33 40%†




Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


12


PLAN 1000/2000 DN

DEDUCTIBLE PLAN 1000- 20%


TRADDED CHOICE DN




INDIVIDUAL/FAMILY

Tier 11 $1,000 / $3,000

Tier 22 $2,000 / $6,000

Tier 33 $3,000 / $9,000




Tier 11 $4,000 / $8,000

Tier 22 $6,000 / $12,000

Tier 33 $7,500 / $15,000

OFFICE VISITS — PRIMARY CARE $25* $25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

OFFICE VISITS — URGENT CARE $45* $45*

Tier 11 $45

Tier 22 $55

Tier 33 40%†


$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

OFFICE VISITS — PRENATAL CARE $0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

OFFICE VISITS — SPECIALTY CARE $35* $35*

Tier 11 $35

Tier 22 $45

Tier 33 40%†

ROUTINE EYE EXAMS $25* $25*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

OUTPATIENT SURGERY 20% of charges 20% of charges

Tier 11 20%†

Tier 22 30%†

Tier 33 40%†



Tier 11 $25 / $100

Tier 22 $35 / 30%†

Tier 33 40%†

CT, MRI, AND PET SCANS $100* $100*

Tier 11 $100

Tier 22 30%†

Tier 33 40%†

EMERGENCY CARE 20% of charges 20% of charges $200

INPATIENT HOSPITAL CARE 20% of charges 20% of charges


Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


13

PLAN 1500/3000 DX


DEDUCTIBLE PLAN 3000 - 20% ADDED CHOICE DX



INDIVIDUAL/FAMILY

Tier 11 $1,500 / $4,500

Tier 22 $3,000 / $9,000

Tier 33 $4,500 / $13,500



Tier 11 $5,000 / $10,000

Tier 22 $6,850 / $13,700

Tier 33 $8,400 / $16,800

$25* $30*

Tier 11 $25

Tier 22 $35

Tier 33 40%†

$45* $50*

Tier 11 $45

Tier 22 $55

Tier 33 40%†

$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$0* $0*

Tier 11 $0

Tier 22 $0

Tier 33 40%†

$35* $40*

Tier 11 $35

Tier 22 $45

Tier 33 40%†

$25* $30*

Tier 11 $25

Tier 22 $35

Tier 33 40%†


Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


Tier 11 $25 / $100

Tier 22 $35 / 30%†

Tier 33 40%†

$100* $100*

Tier 11 $100

Tier 22 30%†

Tier 33 40%†




Tier 11 20%†

Tier 22 30%†

Tier 33 40%†


14

PLAN OPTIONS 83 86 70 71 72 74 75 89E 91 DA DB

DEDUCTIBLE: INDIVIDUAL/FAMILY

Tier 11 $0 $0 $0 $0 $0 $0 $0 $0 $0 $150 / $450

$250 / $750

Tier 22 $200 / $600

$250 / $750

$250 / $750

$300 / $900

$300 / $900

$500 / $1,500

$500 / $1,500

$1,000 / $3,000

$1,500 / $4,500

$300 / $900

$500 / $1,500

Tier 33 $400 / $1,200

$500 / $1,500

$500 / $1,500

$600 / $1,800

$600 / $1,800

$1,000 / $3,000

$1,000 / $3,000

$2,000 / $6,000

$3,000 / $9,000

$450/ $1,350

$750 / $2,250

OUT-OF-POCKET MAXIMUM: INDIVIDUAL/FAMILY (INCLUDES DEDUCTIBLE)

Tier 11 $600 / $1,200

$750 / $1,500

$750 / $1,500

$1,000 / $2,000

$1,000 / $2,000

$1,500 / $3,000

$2,000 / $4,000

$1,000 / $2,000

$3,000 / $6,000

$1,150 / $3,450

$1,250 / $3,750

Tier 22 $1,200 / $3,600

$1,750 / $5,250

$1,750 / $5,250

$1,800 / $5,400

$3,300 / $9,900

$2,500 / $7,500

$3,500 / $10,500

$5,000 / $10,000

$5,500 / $11,000

$2,300 / $6,900

$2,500 / $7,500

Tier 33 $2,150 / $6,450

$3,125 / $9,375

$3,500 / $10,500

$5,100 / $15,300

$6,600 / $19,800

$4,000 / $12,000

$6,500 / $19,500

$8,000 / $16,000

$9,000 / $18,000

$3,450 / $9,900

$3,500 / $10,500

PRIMARY CARE VISIT

Tier 11 $10 $10 $15 $10 $15 $15 $20 $20 $35 $10 $20

Tier 22 $20 $20 $25 $20 $25 $25 $30 $30 $50 $20 $30

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

SPECIALTY CARE VISIT

Tier 11 $20 $20 $25 $20 $25 $25 $30 $30 $45 $20 $30

Tier 22 $30 $30 $35 $30 $35 $35 $40 $40 $60 $30 $40

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

LAB/X-RAY/SPECIAL DIAGNOSTIC PROCEDURES

Tier 11 $10 / $50

$10 / $50

$15 / $50

$10 / $50

$15 / $50

$15 / $50

$20 / $50

$20 / $50

$35 / $50

$10 / $100

$20 / $100

Tier 22 $20 / 20%*

$25 / 20%*

$25 / 20%*

$10 / 10%*

$20 / 20%*

$25 / 10%*

$25 / 20%*

$30 / 20%*

$50 / 30%*

$20 / 20%*

$30 / 20%*

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

URGENT CARE VISIT

Tier 11 $30 $30 $35 $30 $35 $35 $40 $40 $60 $30 $40

Tier 22 $40 $40 $45 $40 $45 $45 $50 $50 $75 $40 $50

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

EMERGENCY CARE

All $200 $200 $200 $200 $200 $200 $200 $200 $200 $200* $200*


Tier 11 $50/day max

$250/admit

$100/day max

$500/admit

$200/admit

$200/admit

$100/day max

$500/admit

$200/day max

$1,000/max

$200/day max

$1,000/admit

$200/day max

$1,000/admit

$800/admit

10%* 10%*

Tier 22 20%* 20%* 20%* 10%* 20%* 10%* 20%* 20%* 30%* 20%* 20%*

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

PLAN HIGHLIGHTS FOR ADDED CHOICE®

POINT-OF-SERVICE PLANS

We recognize that each client has specific needs with regard to their products pairings. Please contact your account manager or sales executive for guidance on which of our traditional and deductible plans best suit your needs when offered alongside an Added Choice plan.1 In most cases, Tier 1 services are provided by Select Providers and Select Facilities. The Evidence of Coverage (EOC) provides a complete definition of Select Provider, Select Facility, and Select Pharmacy. The EOC also explains when Tier 1 services are provided by other providers and facilities.2 Tier 2 services are provided by PPO Providers and PPO Facility. Refer to the Evidence of Coverage (EOC) for a complete definition of PPO Provider and PPO Facility. We provide coverage for certain Tier 2 preventive services with no cost share for out-of-area subscribers and their dependents. See the Preventive Care Services section of your 2017 Evidence of Coverage (EOC) for details.3 Tier 3 services are provided by Non-Participating Providers and Non-Participating Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of Non-Participating Provider and Non-Participating Facility.*Deductible applies.

This brochure provides summaries of various plans and is not a contract. These plans are subject to exclusions and limitations. Plan details, including all benefits, exclusions, and limitations, are provided in the Evidence of Coverage (EOC).

For specific plan information about the plans referred to in this brochure, see the following forms:EWLGPOS0117 EWLGPOSDED0117

PLAN COMPARISON

15

PLAN OPTIONS 83 86 70 71 72 74 75 89E 91 DA DB


Tier 11 $0 $0 $0 $0 $0 $0 $0 $0 $0 $150 / $450

$250 / $750

Tier 22 $200 / $600

$250 / $750

$250 / $750

$300 / $900

$300 / $900

$500 / $1,500

$500 / $1,500

$1,000 / $3,000

$1,500 / $4,500

$300 / $900

$500 / $1,500

Tier 33 $400 / $1,200

$500 / $1,500

$500 / $1,500

$600 / $1,800

$600 / $1,800

$1,000 / $3,000

$1,000 / $3,000

$2,000 / $6,000

$3,000 / $9,000

$450/ $1,350

$750 / $2,250


Tier 11 $600 / $1,200

$750 / $1,500

$750 / $1,500

$1,000 / $2,000

$1,000 / $2,000

$1,500 / $3,000

$2,000 / $4,000

$1,000 / $2,000

$3,000 / $6,000

$1,150 / $3,450

$1,250 / $3,750

Tier 22 $1,200 / $3,600

$1,750 / $5,250

$1,750 / $5,250

$1,800 / $5,400

$3,300 / $9,900

$2,500 / $7,500

$3,500 / $10,500

$5,000 / $10,000

$5,500 / $11,000

$2,300 / $6,900

$2,500 / $7,500

Tier 33 $2,150 / $6,450

$3,125 / $9,375

$3,500 / $10,500

$5,100 / $15,300

$6,600 / $19,800

$4,000 / $12,000

$6,500 / $19,500

$8,000 / $16,000

$9,000 / $18,000

$3,450 / $9,900

$3,500 / $10,500

PRIMARY CARE VISIT

Tier 11 $10 $10 $15 $10 $15 $15 $20 $20 $35 $10 $20

Tier 22 $20 $20 $25 $20 $25 $25 $30 $30 $50 $20 $30

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*


Tier 11 $20 $20 $25 $20 $25 $25 $30 $30 $45 $20 $30

Tier 22 $30 $30 $35 $30 $35 $35 $40 $40 $60 $30 $40

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*


Tier 11 $10 / $50

$10 / $50

$15 / $50

$10 / $50

$15 / $50

$15 / $50

$20 / $50

$20 / $50

$35 / $50

$10 / $100

$20 / $100

Tier 22 $20 / 20%*

$25 / 20%*

$25 / 20%*

$10 / 10%*

$20 / 20%*

$25 / 10%*

$25 / 20%*

$30 / 20%*

$50 / 30%*

$20 / 20%*

$30 / 20%*

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

URGENT CARE VISIT

Tier 11 $30 $30 $35 $30 $35 $35 $40 $40 $60 $30 $40

Tier 22 $40 $40 $45 $40 $45 $45 $50 $50 $75 $40 $50

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

EMERGENCY CARE

All $200 $200 $200 $200 $200 $200 $200 $200 $200 $200* $200*


Tier 11 $50/day max

$250/admit

$100/day max

$500/admit

$200/admit

$200/admit

$100/day max

$500/admit

$200/day max

$1,000/max

$200/day max

$1,000/admit

$200/day max

$1,000/admit

$800/admit

10%* 10%*

Tier 22 20%* 20%* 20%* 10%* 20%* 10%* 20%* 20%* 30%* 20%* 20%*

Tier 33 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%*

PLAN OPTIONS DC DD DE DF DP DN DX DR DS DK


Tier 11 $500 / $1,500

$250 / $750

$500 / $1,500

$500 / $1,500

$750 / $2,250

$1,000 / $3,000

$1,500 / $4,500

$2,000 / $6,000

$3,000 / $9,000

$4,000 / $10,000

Tier 22 $1,000 / $3,000

$500 / $1,500

$1,000 / $3,000

$1,000 / $3,000

$1,500 / $4,500

$2,000 / $6,000

$3,000 / $9,000

$4,000 / $12,000

$6,000 / $12,700

$6,350 / $12,700

Tier 33 $1,500 / $4,500

$750 / $2,250

$1,500 / $4,500

$1,500 / $4,500

$2,250 / $6,750

$3,000 / $9,000

$4,500 / $13,500

$6,000 / $16,800

$8,400 / $16,800

$8,400 / $16,800


Tier 11 $2,000 / $6,000

$1,750 / $5,250

$3,000 / $6,000

$3,000 / $6,000

$2,250 / $4,500

$4,000 / $8,000

$5,000 / $10,000

$5,000 / $10,000

$5,000 / $10,000

$5,000 / $10,000

Tier 22 $4,000 / $12,000

$3,000 / $9,000

$4,750 / $9,500

$5,500 / $11,000

$4,500 / $9,000

$6,000 / $12,000

$6,850 / $13,700

$6,850 / $13,700

$6,850 / $13,700

$6,850 / $13,700

Tier 33 $5,500 / $16,500

$4,000 / $12,000

$6,000 / $12,000

$7,500 / $15,000

$6,000 / $12,000

$7,500 / $15,000

$8,400 / $16,800

$8,400 / $16,800

$8,400 / $16,800

$8,400 / $16,800

PRIMARY CARE VISIT

Tier 11 $20 $20 $20 $30 $25 $25 $25 $25 $30 $30

Tier 22 $30 $30 $30 $40 $35 $35 $35 $35 $40 $40

Tier 33 35%* 45%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%*


Tier 11 $30 $30 $30 $40 $35 $35 $35 $35 $40 $40

Tier 22 $40 $40 $40 $50 $45 $45 $45 $45 $50 $50

Tier 33 35%* 45%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%*


Tier 11 $20 / $100

$20 / $100

$20 / $100

$25 / $100

$25 / $100

$25 / $100

$25 / $100

$25 / $100

$30 / $100

$30 / $100

Tier 22 $30 / 20%*

$30 / 30%*

$30 / 30%*

$35 / 35%*

$35 / 30%*

$35 / 30%*

$35 / 30%*

$35 / 30%*

$40 / 30%*

$40 / 35%*

Tier 33 35%* 45%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%*

URGENT CARE VISIT

Tier 11 $40 $40 $40 $50 $45 $45 $45 $45 $50 $50

Tier 22 $50 $50 $50 $60 $55 $55 $55 $55 $60 $60

Tier 33 35%* 45%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%*

EMERGENCY CARE

All $200* $200* $200* $200* $200* $200* $200* 20%* 20%* $20%*


Tier 11 10%* 20%* 20%* 25%* 20%* 20%* 20%* 20%* 20%* 20%*

Tier 22 20%* 30%* 30%* 35%* 30%* 30%* 30%* 30%* 30%* 35%*

Tier 33 35%* 45%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%*

1 In most cases, Tier 1 services are provided by Select Providers and Select Facilities. The Evidence of Coverage (EOC) provides a complete definition of Select Provider, Select Facility, and Select Pharmacy. The EOC also explains when Tier 1 services are provided by other providers and facilities.2 Tier 2 services are provided by PPO Providers and Non-Participating Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of PPO Provider and PPO Facility. We provide coverage for certain Tier 2 preventive services with no cost share for out-of-area subscribers and their dependents. See the Preventive Care Services section of your 2017 Evidence of Coverage (EOC) for details.3 Tier 3 services are provided by Non-Participating Providers and Non-Participating Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of Non-Participating Provider and Non-Participating Facility.*Deductible applies.


BWLGPOS68160117 BWLGPOS70160117 BWLGPOS71160117 BWLGPOS72160117 BWLGPOS73160117 BWLGPOS74160117 BWLGPOS75160117 BWLGPOS76160117 BWLGPOS83160117

BWLGPOS86160117 BWLGPOS88160117 BWLGPOS89E160117 BWLGPOSDEDDA160117 BWLGPOSDEDDB160117 BWLGPOSDEDDC160117 BWLGPOSDEDDD160117 BWLGPOSDEDDE160117 BWLGPOSDEDDF160117

BWLGPOSDEDDG160117 BWLGPOSDEDDH160117 BWLGPOSDEDDN160117 BWLGPOSDEDDP160117 BWLGPOSDEDDQ160117 BWLGPOSDEDDR160117 BWLGPOSDEDDS160117

16

ALTERNATIVE CARE

Self-referred care, without prior authorization, is available for naturopathic care, chiropractic, acupuncture, and massage therapy. Annual benefit maximums of $500, $1,000 or $1,500 for massage therapy and naturopathic care. Acupuncture services are not subject to the annual benefit maximum. Annual limit of 12 massage therapy visits and 12 acupuncture visits per calendar year, all tiers combined. Office visit copayment will match the cost of the specialty office visit copayment of the medical plan selected.

If you are on an Added Choice® plan with an alternative care benefit, you may use your benefits at The CHP Group (located in our service area), First Choice, or any licensed nonparticipating providers and facilities. The amount an Added Choice member pays is based on the provider. For a list of participating providers, visit www.chpgroup.com.

SUPPLEMENTAL BENEFIT OPTIONS FOR ADDED CHOICE® PLANS

Select Pharmacies MedImpact pharmacies

GENERIC COPAYMENT

PREFERRED BRAND-

NAME DRUG COPAYMENT

NON-PREFERRED

BRAND-NAME DRUG

GENERIC COPAYMENT

PREFERRED BRAND

COPAYMENT*

NON-PREFERRED BRAND

COPAYMENT*

SPECIALTY COPAYMENT

$10 $20 $40 $15 $30 $50$10 $20 $40 $20 $30 $50$10 $20 $40 $20 $40 $60 $300$15 $30 $50 $20 $40 $60$15 $30 $50 $25 $50 $70 $300$20 $40 $60 $30 $60 $80$20 $40 $60 $20 $50 or 50%, whichever Is greater $300

*If a brand drug with an equivalent generic is prescribed and the member requests the brand drug, the charges will be the copayment plus the difference in retail price between generic and brand drug. If the prescriber indicates brand is medically necessary, the member will pay the applicable copayment.


GENERIC COPAYMENT

FORMULARY BRAND

COPAYMENT

NON- FORMULARY

BRAND

SPECIALTY COPAYMENT

GENERIC COPAYMENT

PREFERRED BRAND

COPAYMENT*

NON-PREFERRED BRAND

COPAYMENT*

SPECIALTY COPAYMENT

$10 $20 $40 $150 $20 $40 $60 $300$15 $30 $50 $150 $20 $40 $60 $300$20 $40 $60 $150 $30 $60 $80 $300

*If a brand drug with an equivalent generic is prescribed and the member requests the brand drug, the charges will be the copayment plus the difference in retail price between generic and brand drug. If the prescriber indicates brand is medically necessary, the member will pay the applicable copayment.

VISION HARDWARE COVERAGE

Member pays

12-month allowance For members 19 and above: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or $500 For members 18 and under: No charge for one pair of frames and lenses or contacts every 12 months.

24-month allowance For members 19 and above: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $100, $150, $200, $250, $300, $400, or $500For members 18 and under: No charge for one pair of frames and lenses or contacts every 12 months

HEARING AIDS One hearing aid per ear per three-year period up to: $250, $500, $1,000, $1,500 allowance

17

CHOOSE FROM THE FOLLOWING DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM COMBINATIONS

THEN CHOOSE A COINSURANCE

Deductible (Individual/Family) Out-of-Pocket Maximum (Individual/Family)

Accumulation Type* Available Coinsurance per combination

$1,300/$2,600 $2,600/$5,200 Aggregate 10%, 20%

$1,500/$3,000 $2,500/$5,000 Aggregate 10%, 20%, 30%

$2,000/$4,000 $4,000/$6,550 Aggregate 10%, 20%, 30%, 50%

$2,500/$5,000 $5,000/$6,550 Aggregate 10%, 20%, 30%, 50%

$2,600/$5,200 $5,200/$10,400 Embedded 20%, 30%, 40%, 50%

$3,000/$6,000 $6,000/$12,000 Embedded 20%, 30%, 40%, 50%

$3,500/$7,000 $6,550/$13,100 Embedded 20%, 30%, 40%, 50%

$4,000/$8,000 $6,550/$13,100 Embedded 20%, 30%, 40%, 50%

$5,000/$10,000 $6,550/$13,100 Embedded 20%, 30%, 40%, 50%

$6,550/$13,100 $6,550/$13,100 Embedded 0%

*Aggregate Accumulation: For Services that are subject to the Deductible and Out-of-Pocket Maximum, you must pay Charges for the Services when you receive them, until you meet your Deductible or Out-of-Pocket Maximum. If you are the only Member in your Family, then you must meet the Member Deductible/Out-of-Pocket Maximum. If you are a Member in a Family of two or more Members, you meet the Deductible/Out-of-Pocket Maximum when your entire Family meets the Family Deductible amount. Every Member in your Family must pay charges during the Year until the entire Family meets the Family Deductible or Out-of-Pocket Maximum.

Embedded Accumulation: For Services that are subject to the Deductible and Out-of-Pocket Maximum, you must pay Charges for the Services when you receive them, until you meet your Deductible or Out-of-Pocket Maximum. If you are the only Member in your Family, then you must meet the Member Deductible/Out-of-Pocket Maximum. If there is at least one other Member in your Family, then you must each meet the Member Deductible/Out-of-Pocket Maximum, or your Family must meet the Family Deductible/Out-of-Pocket Maximum, whichever is less. Each Member Deductible amount counts toward the Family Deductible amount. Once the Family Deductible is satisfied, no further Member Deductible will be due for the remainder of the Year.

10% Plan 20% Plan 30% Plan 40% Plan 50% Plan 0% Plan

BENEFIT/FEATURE Member pays Member pays

Member pays

Member pays Member pays

Member pays

OFFICE VISITS — PREVENTIVE AND WELL-CHILD CARE AND PREVENTIVE SERVICES*

$0 $0 $0 $0 $0 $0

OFFICE VISITS — PRENATAL CARE*

$0 $0 $0 $0 $0 $0

OFFICE VISITS — PRIMARY AND URGENT CARE

10% after deductible





0% after deductible







0% after deductible

ROUTINE EYE EXAMS 10% after deductible





0% after deductible

OUTPATIENT SURGERY 10% after deductible





0% after deductible

LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES*






0% after deductible

EMERGENCY CARE 10% after deductible





0% after deductible

HOSPITAL INPATIENT CARE 10% after deductible





0% after deductible

*Deductible does not apply to preventive services.

This brochure provides summaries of various plans and is not a contract. These plans are subject to exclusions and limitations. Plan details, including all benefits, exclusions, and limitations, are provided in the Evidence of Coverage (EOC). For specific information about the plans referred to in this brochure, see the following document: EWLGHDHP0117

PLAN HIGHLIGHTS FOR HSA-QUALIFIED HIGH DEDUCTIBLE HEALTH PLANS

18


BWLGHDHP161CO5P30117BWLGHDHP161CO8P60117BWLGHDHP161CO9P70117BWLGHDHP161CO6P40117BWLGHDHP161C40410117BWLGHDHP1610O5P30117BWLGHDHP1610O8P60117BWLGHDHP1610O9P70117BWLGHDHP1610O6P40117

BWLGHDHP161040410117BWLGHDHP162CO5P30117BWLGHDHP162CO8P60117BWLGHDHP162CO9P70117BWLGHDHP162CO6P40117BWLGHDHP162C40410117BWLGHDHP1620O5P30117BWLGHDHP1620O8P60117BWLGHDHP1620O9P70117

BWLGHDHP1620O6P40117BWLGHDHP162040410117BWLGHDHP1630O5P30117BWLGHDHP1630O8P60117BWLGHDHP1630O9P70117BWLGHDHP1630O6P40117BWLGHDHP163040410117

KAISER PERMANENTE VALUE PLANS

We have developed a new portfolio of plans designed to meet the needs of employers interested in offering coverage that falls within the requirements of a Minimum Value plan under the Affordable Care Act. These plans cover medical essential health benefits, and exclude those services above and beyond essential health benefits that are typically covered under Kaiser Permanente’s standard large group plans.

Excluded non-essential health benefits: routine vision exams for adults (medically necessary eye care is still covered), infertility diagnosis, and dependent children out of area coverage. (See EOC for complete list of exclusions and limitations.)

50% Value Plan 40% Value Plan 30% Value Plan

BENEFIT/FEATURE Member pays Member pays Member pays

DEDUCTIBLE (PER CALENDAR YEAR, EMBEDDED ACCUMULATION)

$3,500 per member / $7,000 per family



OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE, EMBEDDED ACCUMULATION)




OFFICE VISITS — PREVENTIVE AND WELL- CHILD CARE AND PREVENTIVE SERVICES*

$0 $0 $0

OFFICE VISITS — PRENATAL CARE* $0 $0 $0

OFFICE VISITS — PRIMARY AND URGENT CARE

50% after deductible 40% after deductible 30% after deductible

OFFICE VISITS — SPECIALTY CARE 50% after deductible 40% after deductible 30% after deductible

ROUTINE EYE EXAMS 50% after deductible 40% after deductible 30% after deductible

OUTPATIENT SURGERY 50% after deductible 40% after deductible 30% after deductible


50% after deductible 40% after deductible 30% after deductible

EMERGENCY CARE 50% after deductible 40% after deductible 30% after deductible

HOSPITAL INPATIENT CARE 50% after deductible 40% after deductible 30% after deductible

In order to meet minimum value requirements, prescription drug coverage must match plan coinsurance and be subject to the deductible.

PLAN HIGHLIGHTS FOR HSA-QUALIFIED HIGH DEDUCTIBLE HEALTH PLANS

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SUPPLEMENTAL BENEFITS Below are the options available with our high deductible health plans. Contact your sales executive or account manager for more information.

Outpatient prescription drugsThe Kaiser Permanente formulary applies to all plans. Members get up to a 30-day supply for each copayment (up to a 90-day supply of maintenance drugs for two copayments when our Mail-Delivery Pharmacy is used).1 View our formulary at kp.org/formulary.

Options Member pays (after deductible is met)*10% 10% coinsurance (after deductible)

20% 20% coinsurance (after deductible)




$10/$20/$40/$150 $10 generic/$20 brand/$40 non-formulary brand /$150 specialty (after deductible)

$10/$20/$40 $10 generic/$20 brand/$40 non-formulary brand (after deductible)

$10/$30/50%/50% $10 generic/$30 brand/50% non-formulary brand/50% specialty (after deductible)





$15/$30/$50/$150 $15 generic/$30 brand/$50 non-formulary brand/$150 specialty (after deductible)


$20/$40/$60/$150 $20 generic/$40 brand/$60 non-formulary brand/$150 specialty (after deductible)

Note: Prescription drug cost shares apply to the medical out-of-pocket maximum.1Specialty drugs are provided at one copay (or one maximum) for a 30-day supply.*The prescription drug rider may also be purchased with preventive drugs not subject to the deductible. Contact your account manager

for details.

SUPPLEMENTAL BENEFIT OPTIONS FOR HSA-QUALIFIED HIGH DEDUCTIBLE HEALTH PLANS SUPPLEMENTAL BENEFITS

SUPPLEMENTAL BENEFIT OPTIONS FOR HSA-QUALIFIED HIGH DEDUCTIBLE HEALTH PLANS SUPPLEMENTAL BENEFITS

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Chiropractic careSelf-referred chiropractic care is available through The CHP Group–approved network providers in the Kaiser Foundation Health Plan of the Northwest service area. Visit chpgroup.com for a list of providers.

Alternative care (includes chiropractic care)Self-referred alternative care without prior authorization is available from The CHP Group network providers in our service area. Annual benefit maximums of $500, $1,000, or $1,500 for massage therapy and naturopathic care. Acupuncture services are not subject to the annual benefit maximum. Annual limit of 12 massage therapy visits and 12 acupuncture visits per calendar year. Visit chpgroup.com for a list of providers.

Options Member pays$10 $10 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year all

after deductible.

$15 $15 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year all after deductible.

$20 $20 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year all after deductible.

20% coinsurance 20% coinsurance after deductible per chiropractic, acupuncture, naturopathic or massage therapy visit for up to 12 visits per year.

Vision hardware2

Eye exams are covered as a medical benefit at the applicable office visit charge. Vision hardware must be prescribed and purchased at Vision Essentials by Kaiser Permanente. Visit kp2020.org.

Options Member pays12-month allowance For members 19 and older:

Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or $500 For members 18 and younger:No charge for one pair of frames and lenses or contacts every 12 months.

24-month allowance For members 19 and older:Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months. Allowance options: $100, $150, $200, $250, $300, $400, or $500For members 18 and younger:No charge for one pair of frames and lenses or contacts every 12 months.


2Member payments for this benefit do not apply to the medical out-of-pocket maximum or deductible.

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HSA-qualified Added Choice® Plans give your employees the opportunity to combine the cost savings of a high deductible health plan with their desire to keep their current doctor or the option to see any licensed provider for covered services. Only Kaiser Foundation Health Plan of the Northwest offers the option to see any licensed provider across the nation along with exclusive access to Select Providers and Facilities.

PLAN HIGHLIGHTS FOR HSA-QUALIFIED ADDED CHOICE® PLANS

For specific plan information about the plans referred to in this brochure, see the following form: EWLGPOSHSA3T0117

All of the following are non-grandfathered plans:BWLGPOSHSA3T1PS60117BWLGPOSHSA3T2PS60117BWLGPOSHSA3T3PS60117BWLGPOSHSA3T4PS60117

AA1 EE1 EE3 EE4

AGGREGATE EMBEDDED EMBEDDED EMBEDDED

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 1 2 3 1 2 3


$1,500 $2,500 $3,500 $2,600 $3,600 $4,600 $2,600 $3,600 $4,600 $2,600 $3,600 $4,600

DEDUCTIBLE PER FAMILY

$3,000 $5,000 $7,000 $5,200 $7,200 $9,200 $5,200 $7,200 $9,200 $5,200 $7,200 $9,200


$2,500 $4,000 $5,000 $4,000 $5,000 $6,000 $5,200 $6,200 $9,200 $5,200 $6,200 $9,200


$5,000 $6,550 $10,000 $8,000 $10,000 $12,000 $10,400 $12,400 $18,400 $10,400 $12,400 $18,400


$0 20% 30% $0 20% 30% $0 20% 30% $0 30% 40%


$0 20% 30% $0 20% 30% $0 20% 30% $0 30% 40%


10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%


10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%


10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%

ROUTINE EYE EXAMS

10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%

OUTPATIENT SURGERY

10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%

LAB VISITS 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%


10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%

EMERGENCY CARE 10% 10% 10% 20%


10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40%

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SUPPLEMENTAL BENEFIT OPTIONS FOR HSA-QUALIFIED ADDED CHOICE® PLANS

SUPPLEMENTAL BENEFITSBelow are the options available with our HSA-qualified Added Choice® Plans. Contact your sales executive or account manager for more information.

Outpatient prescription drugsThe Kaiser Permanente formulary applies to all plans. Members get up to a 30-day supply for each copayment (up to a 90-day supply of maintenance drugs for two copayments when our Mail-Delivery Pharmacy is used).1 View our formulary at kp.org/formulary. Note: Prescription drug cost shares apply to the medical out-of-pocket maximum.1Specialty drugs are provided at one copay (or one maximum) for a 30-day supply.


GENERIC COPAYMENT

FORMULARY BRAND COPAYMENT

NON-FORMULARY BRAND COPAYMENT

GENERIC COPAYMENT

FORMULARY BRAND COPAYMENT2

NON-FORMULARY BRAND COPAYMENT2

$10 $20 $40 $15 $30 $50

$15 $30 $50 $20 $40 $60

$20 $40 $60 $30 $60 $80

20% coinsurance 30% coinsurance

2 If a brand drug with an equivalent generic is prescribed and the member requests the brand drug, the charges will be the copayment plus the difference in retail price between the generic and the brand drug. If the prescriber indicates brand is medically necessary, the member will pay the applicable copayment.

Alternative care Self-referred care, without prior authorization, is available for naturopathic care, chiropractic, acupuncture, and massage therapy. Annual benefit maximums of $500, $1,000 or $1,500 for massage therapy and naturopathic care. Acupuncture services are not subject to the annual benefit maximum. Annual limit of 12 massage therapy visits and 12 acupuncture visits per calendar year, all tiers combined. Office visit copayment will match the cost of the specialty office visit copayment of the medical plan selected. To be covered by your benefit, you must receive care from a provider in our service area who is part of The CHP Group network. If you are on an Added Choice® plan with an alternative care benefit, you may use your benefits at The CHP Group (located in our service area), First Choice, or any licensed nonparticipating providers and facilities. The amount an Added Choice member pays is based on the provider. For a list of participating providers, visit www.chpgroup.com.

VISION HARDWARE COVERAGE Member pays

12-month allowance For members 19 and above: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or $500 For members 18 and under: No charge for one pair of frames and lenses or contacts every 12 months.

24-month allowance For members 19 and above: Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months. Allowance options: $100, $150, $200, $250, $300, $400, or $500 For members 18 and under: No charge for one pair of frames and lenses or contacts every 12 months


A BETTER WAY WASHINGTON 2017 - Kaiser …...the high-quality integrated care that sets Kaiser...

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