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Kaiser Foundation Health Plan of the Northwest

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
- How we pay providers
- Your Rights
- Service Area
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
- Identification cards
- Where you get covered care
  - Plan providers
  - Plan facilities
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Copayments
- Deductible
- Coinsurance
- Fees when you fail to make your copayment
- Fees when you miss a medical appointment
- Your catastrophic protection out-of-pocket maximum for copayments and coinsurance
Section 5. Benefits -- Overview
- Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5 (c). Services provided by a hospital or other facility, and ambulance services
- Section 5 (d). Emergency services/accidents
- Section 5 (e). Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
- Section 5 (g). Special features
- Section 5 (h). Dental benefits
- Section 5 (i). Non-FEHB benefits available to Plan members
Section 6. General exclusions -- things we dont cover
Section 7. Filing a claim for covered services
- Medical, hospital, and drug benefits
- Deadline for filing your claim
- When we need more information
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
- TRICARE and CHAMPVA
- Workers Compensation
- Medicaid
- When other Government agencies are responsible for your care
- When others are responsible for injuries
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- No pre-existing condition limitation
- Where you can get information about enrolling in the FEHB Program
- Types of coverage available for you and your family
- Childrens Equity Act
- When benefits and premiums start
- When you retire
- When you lose benefits
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for Kaiser Foundation Health Plan of the Northwest Standard Option 2003
Summary of benefits for Kaiser Foundation Health Plan of the Northwest High Option 2003
2003 Rate Information

Pages 1--74

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

Kaiser Foundation Health Plan of the Northwest
http:// www. kp. org/ nw
2003 A Health Maintenance Organization

Serving: Portland and Salem, Oregon Vancouver and Longview, Washington
Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 8 for requirements.

Enrollment codes for this Plan:
571 High Option Self Only 572 High Option Self and Family
574 Standard Option Self Only 575 Standard Option Self and Family

RI 73-004

This Plan has excellent
accreditation from the NCQA.
See the 2003 Guide for more
information on accreditation.

For changes
in benefits
see page 9 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB)
Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this
notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:

To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information
for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except
if OPM has already acted based on your permission.

By law, you have the right to:

See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information
is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your
personal medical information.

Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information

that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health
care or a disputed claim. 3.
3 Page 4 5

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the Web. You may
also call 202/ 606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary
of the Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days
of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

Plan providers....................................................................................................................................... 10
Plan facilities ........................................................................................................................................ 10
What you must do to get covered care ........................................................................................................ 10

When FEHB coverage ends ................................................................................................................. 64 6.
6 Page 7 8

2003 Kaiser Foundation Health Plan of the Northwest 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Kaiser Foundation Health Plan of the Northwest under our contract (CS 1047) with
the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for
Kaiser Foundation Health Plan of the Northwest's administrative office is:

Kaiser Foundation Health Plan of the Northwest
500 N. E. Multnomah Street, Suite 100
Portland, Oregon 97232-2099

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in self and
family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that
were available before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 9. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public.
For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" or "Plan" means Kaiser Foundation Health Plan of the Northwest.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation, 1900 E Street NW,
Washington, DC 20415.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services. 8.
8 Page 9 10
2003 Kaiser Foundation Health Plan of the Northwest 6 Introduction/ Plain Language/ Advisory
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us from Portland at 503/ 813-2000, or from other areas call 800/ 813-2000, or our TTY numbers in Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388 and

explain the situation.
If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in
the Plan. 9.
9 Page 10 11

2003 Kaiser Foundation Health Plan of the Northwest 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible
for the selection of these providers in your area. Contact the Plan for a copy of our most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any
course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the
copayments and coinsurance described in this brochure. When you receive emergency services or services covered under
the travel benefit from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You
cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or
other provider will be available and/ or remain under contract with us.

How we pay providers
The Northwest Permanente Medical Group provides patient care services through a group capitation arrangement with
Kaiser Foundation Health Plan of the Northwest. Northwest Permanente physicians provide approximately 98% of primary
care services and more than 80% of specialty services to members. The Medical Group receives a lump sum incentive
payment within a narrow range at the end of the year based on financial performance of the Health Plan and the Medical
Group against budget. Compensation for physicians is designed to be competitive in order to recruit and retain quality
physicians. Physicians in the Medical Group do not receive financial incentives linked to individual utilization patterns.
Instead, approximately ninety percent or more of compensation received by individual physicians is salary; and the
remaining amount of variable compensation is based on clinical quality, patient satisfaction and financial performance of
the Medical Group and the Health Plan.

Your Rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us,
our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is listed below.

We are a federally qualified health maintenance organization. Kaiser Foundation Health Plan of the Northwest is a non-profit
corporation. Kaiser Permanente began offering medical services to workers and their families at Grand Coulee Dam
in northeastern Washington and later the Kaiser shipyards in Portland, Oregon and Vancouver, Washington during World
War II. When the shipyards were closed in 1945, enrollment was opened to the community. This Plan is part of the Kaiser
Permanente Medical Care Program, a group of not-for-profit organizations and contracting medical groups that serve over 8
million members nationwide.

In 1995, Kaiser Permanente became the first HMO in Oregon and southwest Washington to receive a three-year, full
accreditation from the National Committee for Quality Assurance (NCQA). We were again awarded three-year, full
accreditation in 1998. In 2001, we were awarded the highest level of accreditation, known as "Excellent Accreditation."
Excellent Accreditation status is awarded to plans whose service and clinical quality meet or exceed NCQA's rigorous
requirements for consumer protection and quality improvement, and whose HEDIS (Health Plan Employer Data and
Information Set) results are in the highest range of national performance.

All Kaiser Permanente and affiliated hospitals are accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). 10.
10 Page 11 12

2003 Kaiser Foundation Health Plan of the Northwest 8 Section 1
All applicants for employment with Northwest Permanente P. C., or Permanente Dental Associates must meet rigorous
Kaiser Permanente credentialing standards. Once hired, they undergo periodic review by peers and hospital boards to
assure their credentials are up to date and in order.

If you want more information about us, from Portland, call 503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY
numbers in Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388, or write to Kaiser Foundation Health Plan of the
Northwest, 500 N. E. Multnomah Suite 100, Portland, OR 97232. You may also visit our Web-site at www. kp. org/ nw.

Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area is:
These Oregon counties: Columbia, Multnomah, Polk, Yamhill
And these Oregon ZIP codes:
Benton County: 97330, 97331, 97333, 97339, 97370
Clackamas County: 97004, 97009, 97011, 97013, 97015, 97017, 97022-23, 97027, 97034-36, 97038, 97042, 97045, 97055,
97067-68, 97070, 97222, 97267-68

Linn County: 97321, 97335, 97355, 97358, 97360, 97374, 97389
Marion County: 97002, 97020, 97026, 97032, 97071, 97137, 97301-3, 97305-14, 97325, 97352, 97359, 97362, 97375,
97381, 97383-85, 97392

Washington County: 97005-8, 97062, 97075-78, 97106, 97109, 97113, 97116-17, 97119, 97123-25, 97133, 97140, 97144,
97223-25, 97229, 97281, 97291

These Washington counties: Clark County
And these Washington ZIP codes:
Cowlitz County: 98581, 98603, 98609, 98611, 98616, 98625-26, 98632, 98645, 98649, 98674
Lewis County: 98591, 98593, 98596
Wahkiakum County: 98612, 98647

Ordinarily, you must receive your care from physicians, hospitals, and other providers who contract with us. However, we
are part of the Kaiser Permanente Medical Care Program, and if you are visiting another Kaiser Permanente service area,
you can receive virtually all of the benefits of this Plan at any other Kaiser Permanente facility, including our mail order
prescription program. You must pay the charges or copayments imposed by the Kaiser Permanente Plan you are visiting,
with the exception of mail order prescriptions which are administered by your home Plan. See Section 5( g), Special
Features, for more details. We also pay for certain follow-up services or continuing care services while you are traveling
outside the service area, as described on page 45; and for emergency care obtained from any non-Plan provider, as
described on page 36. We will not pay for any other health care services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents
live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not
have to wait until Open Season to change plans. Contact your employing or retirement office. 11.
11 Page 12 13
2003 Kaiser Foundation Health Plan of the Northwest 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Changes apply to both Standard and High Options unless otherwise noted.

Your share of the non-Postal premium will increase by 21. 4% for Self Only or 21. 2% for Self and Family under the High Option and will increase by 14.2% for Self Only or 14.2% for Self and Family under the Standard Option.

We have added a new continuity of care provision to comply with an Oregon State mandate.
We assess a $10 fee for non-payment of copayments at the time of service.
We assess a $10 fee for missed appointments, unless you notified us in advance.
We cover physical and occupational therapy up to the greater of 20 visits or 2 months per condition for each therapy.
We cover speech therapy up to the greater of 20 visits or 2 months per condition for each therapy.
We redesigned your vision benefit.
We cover orthopedic and some prosthetic devices, including TMJ splint and post-mastectomy bras, at 50% of our allowance.

We increased the copayment for ambulance services from $25 per transport to $75 per transport.
We cover emergency room visits both inside and outside the service area at $75 per visit, and urgent care visits both inside and outside the service area at your office visit copayment.

We cover injectable contraceptives at $15 generic/$ 30 brand name drug copayment under the Standard Option and at $10 generic/$ 20 brand name drug copayment under the High Option. 12.
12 Page 13 14
2003 Kaiser Foundation Health Plan of the Northwest 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or obtain a prescription at a Plan pharmacy. Until
you receive your ID card, use your copy of the Health Benefits Election Form,
SF-2809, your health benefits enrollment confirmation (for annuitants), or your
Employee Express confirmation letter

If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us from Portland at
503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY numbers in
Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388, or write to us at:
Membership Accounting Department, Customer Service Center, Kaiser Foundation
Health Plan of the Northwest, 6777 Camp Bowie Boulevard, Fort Worth, Texas
97116.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims.

Plan providers The Plan contracts with Northwest Permanente, P. C. to provide physician services. They practice in medical offices located within our service area. Permanente
Dental Associates, an independent group of dentists, provides or arranges dental
care for members of the High Option plan.

We list Plan providers in the provider directory, which we update periodically. The
list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. Medical Centers, Medical
Offices and Dental Offices are conveniently located throughout Portland and
Salem, Oregon and Vancouver and Longview-Kelso, Washington. Inpatient care is
available at Kaiser Sunnyside Medical Center, Providence St. Vincent Medical
Center, Providence Portland Medical Center, Southwest Washington Medical
Center, Salem Hospital, St. John Medical Center, Doernbecher Children's Hospital
(for children only), and Legacy Emanuel Hospital and Health Center (for low risk
childbirth services). We list these in the provider directory, which we update
periodically. The list is also on our Web-site.

You must receive your health services at Plan facilities, except if you have an
emergency. If you are visiting another Kaiser Permanente service area, you may
receive health care services at those Kaiser Permanente facilities. Under the
circumstances specified in this brochure you may receive follow-up or continuing
care while you travel anywhere.

What you must do to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary
care physician provides or arranges for most of your health care. Our Web-site has
information about our providers. Membership Services can help you too, by telling
you who is available and sharing information about them. To choose or change a
primary care physician, call Membership Services from Portland at 503/ 813-2000,
or from other areas call 800/ 813-2000 or our TTY numbers in Oregon at
800/ 735-2900 and in Washington at 800/ 833-6388. 13.
13 Page 14 15
2003 Kaiser Foundation Health Plan of the Northwest 11 Section 3
Primary care Your primary care physician can be a physician, nurse practitioner, or physician assistant in family practice, internal medicine, or pediatrics. Your primary care
physician will provide most of your health care, or give you a referral to see a
specialist.

If you want to change primary care physicians or if your primary care physician
leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care physician
authorized a certain number of visits without additional referrals. The primary
care physician must provide or authorize all follow-up care. Do not go to the
specialist for return visits unless your primary care physician gives you a referral.
However, a woman may see her obstetrician/ gynecologist without having to
obtain a referral. You may also receive outpatient alcohol and drug treatment,
cancer counseling, eye examinations, outpatient mental health, chiropractic,
occupational health, and social work services without a referral.

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number of
visits without additional referrals. Your primary care physician will use our
criteria when creating your treatment plan.

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you
need. If he or she decides to refer you to a specialist, ask if you can see your
current specialist. If your current specialist does not participate with us, you
must receive treatment from a specialist who does. Generally, we will not pay
for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist.
You may receive services from your current specialist until we can make
arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and
you enroll in another FEHB plan; or

reduce our service area and you enroll in another FEHB plan,
you may be able to continue seeing your specialist for up to 90 days after you
receive notice of the change. Contact us or, if we drop out of the Program,
contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90 days. 14.
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2003 Kaiser Foundation Health Plan of the Northwest 12 Section 3
Note: Under certain circumstances and for a limited period of time, we may
continue to pay for covered services provided by your Kaiser Permanente
physician or a physician you have been referred to by your Kaiser Permanente
physician, when the physician's contract with us has been terminated. This
extension of care is available for a period up to 120 days from the date we notify
you of the physician's termination, as long as you are receiving an active course of
medically necessary treatment, and your treating physician agrees that it is
desirable to maintain continuity of care. Additionally, this extension of coverage
is available if you are in the second trimester of pregnancy, until the later of the
following dates: the 45th day after the baby's birth, or as long as you are receiving
active treatment, not to exceed 120 days from the date you receive notice of the
termination. To apply for this continuity of care extension, you must submit a
written request to us.

This continuity of care provision is applicable only when your Kaiser Permanente
physician or referred physician agrees to adhere to the reimbursement rate
applicable at the time of contract termination or an equivalent rate, if the
contractual rate was not based on a fee-for-service basis.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled
nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our
Membership Services department immediately from Portland at 503/ 813-2000, or
from other areas call 800/ 813-2000 or our TTY numbers in Oregon at
800/ 735-2900 and in Washington at 800/ 833-6388. If you are new to the FEHB
Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:

you are discharged, not merely moved to an alternative care center; or
the day your benefits from your former plan run out; or
the 92 nd day after you become a member of this Plan;
whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will
make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Most care and service is not subject to administrative prior authorization. Prior authorization is required for select services such as care at skilled nursing
facilities, home health and hospice services, referrals to non-Kaiser Permanente
physicians, and transplants. Your primary care physician will give a referral for
these services if they are medically necessary. 15.
15 Page 16 17
2003 Kaiser Foundation Health Plan of the Northwest 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician, you pay a copayment of
$10 per office visit if you are on the High Option Plan and $15 per office visit if
you are on the Standard Plan. When you go in the hospital, you pay nothing under
either Option.

Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for certain services you receive.

Example: In our Plan, you pay 50% of our allowance for infertility services.
Fees when you fail to make your copayment If you do not pay your copayment at the time you receive services, we will bill you. You will be required to pay a $10 charge for each bill sent unpaid services.

Fees when you miss a medical appointment If you miss a medical appointment, we will charge you $10, unless you notify us in advance.
Your catastrophic protection out-of-pocket
maximum for copayments and coinsurance

After your copayments and coinsurance total $600 per person or $1, 200 per
family enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not count
toward your catastrophic protection out-of-pocket maximum. You must continue
to pay copayments for these services under both the High Option and
Standard Option.

Outpatient prescription drugs Contraceptive devices
Dental services Corrective appliances and artificial aids
The $25 charges paid for follow-up or continuing care when you are traveling out of our service area
Long-term physical therapy and rehabilitation Eyeglasses and contact lenses
Health education services
Be sure to keep accurate records of your copayments and coinsurance since you
are responsible for informing us when you reach the maximum. 16.
16 Page 17 18

2003 Kaiser Foundation Health Plan of the Northwest 14 Section 5
Section 5. Benefits --Overview
(See page 9 for how our benefits changed this year and pages 68 and 69 for benefit summaries.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us from Portland
at 503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY numbers in Oregon at 800/ 735-2900 and in Washington
at 800/ 833-6388 or at our website at www. kp. org/ nw.

(a) Medical services and supplies provided by physicians and other health care professionals...................................... 15-26
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests

Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Treatment therapies
Physical and occupational therapies Speech therapy

Hearing services (testing, treatment, and supplies) Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................. 27-30
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants

Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services.............................................................. 31-34

Inpatient hospital Outpatient hospital or ambulatory surgical

center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ................................................................................................................................... 35-37
Emergency within our service area Emergency outside our service area Ambulance

(e) Mental health and substance abuse benefits .............................................................................................................. 38-40
(f) Prescription drug benefits .......................................................................................................................................... 41-43
(g) Special features.......................................................................................................................................................... 44-46

Flexible benefits option 24 hour nurse line

Services for deaf and hearing impaired Language interpretation
High risk pregnancies Centers of Excellence
Travel benefit Services from other Kaiser Permanente Plans

(h) Dental benefits ........................................................................................................................................................... 47-50
(i) Non-FEHB benefits available to Plan members ............................................................................................................. 51
Summary of benefits ......................................................................................................................................................... 68-69 17.
17 Page 18 19
2003 Kaiser Foundation Health Plan of the Northwest 15 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
Note: We waive the $10 charge if you enroll in our Medicare+ Choice Plan and assign your Medicare benefits to the Plan.

I M
P O
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T

Benefit Description You pay
Diagnostic and treatment services You pay -Standard Option You pay -High Option
Professional services of physicians and other health
care professionals

In a physician's office
Office medical consultations
In a Plan urgent care center
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment

Second surgical opinion

$15 per office visit $10 per office visit

Professional services of physicians and other health
care professionals

During a hospital stay

Nothing Nothing

At home Nothing Nothing 18.
18 Page 19 20
2003 Kaiser Foundation Health Plan of the Northwest 16 Section 5( a)
Lab, X-ray, and other diagnostic tests You pay -Standard Option You pay -High Option
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing Nothing

Preventive care, adult
Routine screenings, such as:
Total blood cholesterol
Colorectal cancer screening, including
Fecal occult blood test
Sigmoidoscopy -every five years starting at
age 50

Routine Prostate Specific Antigen (PSA) test -one annually for men age 40 and older

Routine pap test
Note: You should consult with your physician to
determine what is appropriate and medically
necessary for you.

Note: You will pay only one copayment if you
receive your routine screening on the same day as
your office visit.

$15 per office visit $10 office visit

Routine mammogram covered for women age 35
and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years
Note: In addition to routine screening, we cover
mammograms when medically necessary to
diagnose or treat your illness.

Nothing Nothing

Preventive care, adult --continued on next page 19.
19 Page 20 21
2003 Kaiser Foundation Health Plan of the Northwest 17 Section 5( a)
Preventive care, adult (continued) You pay -Standard Option You pay -High Option
Routine immunizations and boosters Nothing Nothing
Visits to receive injections $5 per office visit $5 per office visit
Injectable travel immunizations
Note: We cover oral travel immunizations under
the prescription drug benefit.

$15 per office visit $10 per office visit

Not covered:
Physical exams required for:

Obtaining or continuing employment
Insurance
Attending schools

All charges All charges

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing Nothing

Examinations, such as:
Eye exams to determine the need for vision
correction

Ear exams to determine the need for hearing
correction

Examinations done on the day of
immunizations

Well-child care charges for routine examinations, immunizations, and care

$15 per office visit $10 per office visit

Injectable travel immunizations
Note: We cover oral travel immunizations under
the prescription drug benefit.

$15 per office visit $10 per office visit

Not covered:
Physical exams required for:

Obtaining or continuing employment
Insurance
Attending schools or camp

All charges All charges 20.
20 Page 21 22
2003 Kaiser Foundation Health Plan of the Northwest 18 Section 5( a)
Maternity care You pay -Standard Option You pay -High Option
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours

after a cesarean delivery. Your physician will
extend your inpatient stay if medically
necessary.

We cover routine nursery care of the newborn child during the covered portion of the

mother's maternity stay. We will cover other
care of an infant who requires non-routine
treatment only if we cover the infant under a
Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury.

See Section 5( c) for hospital benefits and
Section 5( b) for surgery benefits.

$15 per office visit $10 per office visit

Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges All charges

Family planning
Family planning services including counseling

Voluntary sterilization (See Surgical procedures Section 5( b))
Surgically implanted time-release contraceptives and intrauterine devices
(IUDs)
Note: In addition to the office visit copayment for
surgical procedures related tointernally implanted
time-release contraceptive drugs and
contraceptive devices, we charge for the drug or
device according to your Prescription Drug
benefit. Other contraceptive drugs and
diaphragms are also covered under your
Prescription Drug benefit.

$15 per office visit $10 per office visit

Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling

All charges All charges 21.
21 Page 22 23
2003 Kaiser Foundation Health Plan of the Northwest 19 Section 5( a)
Infertility services You pay -Standard Option You pay -High Option
Diagnosis and treatment of involuntary infertility
including artificial insemination limited to
intrauterine insemination (IUI)

50% of our allowance 50% of our allowance

Not covered:
These exclusions apply to fertile as well as
infertile individuals or couples:

Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Assisted reproductive technology (ART) procedures, such as:

In vitro fertilization
Embryo transfer and gamete intrafallopian
transfer (GIFT)

Services and supplies related to excluded ART procedures

Cost of donor sperm and donor eggs and services related to their procurement and
storage
Drugs used in the diagnosis and treatment of infertility

All charges All charges

Allergy care
Testing and treatment $15 per office visit $10 per office visit
Allergy injections $5 per office visit $5 per office visit
Allergy serum Nothing Nothing
Not covered:
Provocative food testing
Sublingual allergy desensitization

All charges All charges 22.
22 Page 23 24
2003 Kaiser Foundation Health Plan of the Northwest 20 Section 5( a)
Treatment therapies You pay -Standard Option You pay -High Option
Chemotherapy and radiation therapy
Note: We limit high dose chemotherapy in
association with autologous bone marrow
transplants to those transplants listed under
Organ/ Tissue Transplants on page 30.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis

Intravenous (IV)/ Infusion Therapy home IV and antibiotic therapy
Note: We cover growth hormone therapy (GHT)
under the Prescription Drug benefit on page 41.

$15 per office visit $10 per office visit

Not covered:
Long-term rehabilitative therapy
Chemotherapy supported by a bone marrow transplant or with stem cell support, for any

diagnosis not listed as covered
Cognitive therapy

All charges All charges

Physical and occupational therapies
Benefit is limited to the greater of 20 visits or 2
months per condition for each therapy:

Physical therapy by qualified physical therapists to restore bodily function when

you have a total or partial loss of bodily
function due to illness or injury

Occupational therapy is limited to services that assist the member to achieve and

maintain self-care and improved functioning
in other activities of daily living

Cardiac rehabilitation following a heart
transplant, bypass surgery, or a myocardial
infarction.

$15 per outpatient visit
Nothing for inpatient
$10 per outpatient visit
Nothing for inpatient

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges All charges 23.
23 Page 24 25
2003 Kaiser Foundation Health Plan of the Northwest 21 Section 5( a)
Speech therapy You pay -Standard Option You pay -High Option
Benefit is limited to the greater of 20 visits or 2
months per condition for each therapy:

Speech therapy by speech pathologists when medically necessary

$15 per outpatient visit
Nothing for inpatient
$10 per outpatient visit
Nothing for inpatient

Not covered:
Speech therapy that is not medically necessary
such as:

Therapy for educational placement or other educational purposes

Training or therapy to improve articulation in the absence of injury, illness, or medical
condition affecting articulation
Therapy for tongue thrust in the absence of swallowing problems

All charges All charges

Hearing services (testing, treatment, and supplies)
Ear and hearing examinations to determine the need for hearing correction
Hearing testing for children through age 17 (see Preventive care, children)

$15 per office visit $10 per office visit

Not covered:
All other hearing testing
Hearing aids and supplies

All charges All charges

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye
Eye refractions

$15 per office visit $10 per office visit

Lenses, frames, industrial safety glasses and/ or medically necessary contact lenses
every 24 months
Medically necessary contact lenses for:
Extremely high degrees of near or
farsightedness

Distorted corneas which limit the best
visual acuity with glasses

Visual error of the two eyes which are
greatly different in power

The cost of lenses,
frames, industrial safety
glasses, and/ or medically
necessary contact lenses
less $100

The cost of lenses,
frames, industrial
safety glasses, and/ or
medically necessary
contact lenses less
$150

Vision services (testing, treatment, and supplies) --continued on next page 24.
24 Page 25 26
2003 Kaiser Foundation Health Plan of the Northwest 22 Section 5( a)
Vision services (testing, treatment, and supplies) (continued) You pay -Standard Option You pay -High Option
You may select non-medically necessary contact lenses instead of lenses, frames,
and/ or industrial safety glasses.

The cost of contact lenses
less $100
The cost of contact
lenses less $150

Eyeglasses and contact lens( es) after cataract surgery with intraocular lens implant:
-Medically necessary intraocular lenses
-One pair of eyeglasses (regular lenses and
designated frames); or

-One pair of contact lenses

Nothing Nothing

Eyeglasses and contact lens( es) after cataract surgery not involving intraocular lens implant:
-One pair of contact lenses and/ or one pair of
designated frames and regular lenses if both
must be worn at the same time to provide a
significant improvement in visual acuity or
binocular vision not obtainable with regular
lenses or contact lens( es) alone

Nothing Nothing

What you should know:
Vision care benefits are provided to members
when prescribed by Plan physicians or
optometrists and provided at Plan facilities and
optical departments.

Your vision care benefits for lenses, frames,
industrial safety glasses and/ or medically
necessary contact lenses renews every 24 months
from the date you last received them.

$60 for single vision and
cosmetic contact lenses;

$90 for multifocal lenses

$60 for single vision and
cosmetic contact lenses;

$90 for multifocal lenses

If a significant change in correction occurs in one
or both eyes within 12 months of the initial exam,
we cover lenses, industrial safety lenses or
medically necessary contact lenses with the new
correction at these maximum values.
Replacement coverage is for the original product
type (contacts or eyeglasses) only.

If you have selected non-medically necessary
contact lenses in lieu of lenses and frames, and/ or
industrial safety glasses, and a significant change
in correction occurs in one or both eyes within 12
months of the initial exam, we will cover
replacement of non-medically necessary contact
lenses at these maximum values. Replacement
coverage is for the original product type (contacts
or eyeglasses) only.

Vision services (testing, treatment, and supplies) --continued on next page 25.
25 Page 26 27
2003 Kaiser Foundation Health Plan of the Northwest 23 Section 5( a)
Vision services (testing, treatment, and supplies) (continued) You pay -Standard Option You pay -High Option
Not covered:
Repair or replacement of broken, lost, or stolen lenses or frames

Contacts having no refractive value
Fitting and routine follow-up services for non-medically indicated contact lenses

Refractions for non-medically indicated contact lenses
Vision therapy (orthoptics or eye exercises)
Radial keratotomy, Photorefractive Keratectomy and other refractive surgery

such as Lasik surgery and evaluations for
these procedures

Visual training
Low vision aids

All charges All charges

Foot Care
Routine foot care when you are under active
treatment for a metabolic or peripheral vascular
disease, such as diabetes

$15 per office visit $10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails and

similar routine treatment of conditions of
the foot

Treatment of weak, strained or flat feet or bunions or spurs of any instability, imbalance

or subluxation of the foot

All charges All charges

Orthopedic and prosthetic devices
Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted
breast implant following mastectomy. Note:
See Section 5( c) for payment information
and Section 5( b) for coverage of the surgery
to insert the device.

Nothing Nothing

Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Corrective orthopedic appliances for nondental treatment of temporomandibular

joint (TMJ) pain dysfunction syndrome

50% of our allowance 50% of our allowance

Orthopedic and prosthetic devices --continued on next page 26.
26 Page 27 28
2003 Kaiser Foundation Health Plan of the Northwest 24 Section 5( a)
Orthopedic and prosthetic devices (continued) You pay -Standard Option You pay -High Option
Maxillo-facial prosthetic devices to restore or
manage head and facial structures that are
defective

20% of our allowance 20% of our allowance

When prescribed by a Plan physician, we cover
orthopedic and other prosthetic devices not listed
above, including repairs, adjustments or
replacements other than those necessitated by
misuse or loss.

Note: We cover only those standard items that
are adequate to meet the medical needs of the
member.

Note: Orthopedic and other prosthetic devices are
provided in accordance with the Plan's DME
formulary and its guidelines.

50% of our allowance 50% of our allowance

Not covered:
Devices used primarily for cosmetic purposes that are not necessary to control or eliminate

infection, pain, or restore functions such as
speech, swallowing, or chewing

Artificial larynxes
Voice machines
Artificial hearts
Internally implanted insulin pumps
Dentures (except High Option)
External and internally implanted hearing aids
Devices, equipment, supplies, and prosthetics related to the treatment of sexual dysfunction

Orthotic devices including corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges All charges 27.
27 Page 28 29
2003 Kaiser Foundation Health Plan of the Northwest 25 Section 5( a)
Durable medical equipment (DME) You pay -Standard Option You pay -High Option
When prescribed by a Plan physician, we cover
or purchase, at our option, durable medical
equipment intended to be used repeatedly and in
the home.

Necessary repairs, adjustments, and replacements
other than those necessitated by misuse or loss
are also covered.

Note: We cover only those standard items that
are adequate to meet the medical needs of the
member.

Note: DME-related supplies are provided in
accordance with the Plan's DME formulary and
its guidelines.

Note: DME-related supplies for the treatment of
diabetes are covered under your Prescription
Drug benefit.

50% of our allowance 50% of our allowance

Home health services
If you are homebound and reside in the service area:
You may receive home health services of nurses and health aides, physical or occupational

therapists, and speech and language pathologists,
when prescribed by your plan physician, who
will periodically review the program for
continuing appropriateness and need

Services include oxygen therapy, intravenous therapy, and medications

Nothing Nothing

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's

family
Home care primarily for personal assistance that does not include a medical component

and is not diagnostic, therapeutic, or
rehabilitative

Services outside our service area

All charges All charges 28.
28 Page 29 30
2003 Kaiser Foundation Health Plan of the Northwest 26 Section 5( a)
Chiropractic You pay -Standard Option You pay -High Option
Chiropractic services up to 20 visits per calendar year
Services include evaluation and management, musculoskeletal treatments, physical therapy

modalities such as hot and cold packs, and X-rays
Note: You must choose the chiropractor from our
list of Participating Chiropractors. Contact us to
get the list. You may see a chiropractor without
referral from your Plan physician.

$20 per office visit $15 per office visit

Not covered:
Non-neuroskeletal disorders
Vocational rehabilitation services
Laboratory services; MRI or other type of advanced diagnostic radiology

Durable medical equipment or supplies for use in the home

All charges All charges

Alternative treatments
No benefit All charges All charges

Education classes and programs
No benefit All charges All charges 29.
29 Page 30 31
2003 Kaiser Foundation Health Plan of the Northwest 27 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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T

including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility

(i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRE-AUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the pre-authorization shown in Section 3 to be sure which

services and surgeries require pre-authorization.

I M
P O
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T

Benefit Description You pay
Surgical procedures You pay -Standard Option You pay -High Option
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon

Pre-surgical testing
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)

Surgical treatment of morbid obesity -a condition in which an individual weighs 100
pounds or 100% over his or her normal
weight according to current underwriting
standards; eligible members must be age 18
or over

Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and prosthetic

devices for coverage information

$15 per office visit for
outpatient services

Nothing for inpatient
services

$10 per office visit for
outpatient services

Nothing for inpatient
services

Surgical procedures --continued on next page 30.
30 Page 31 32
2003 Kaiser Foundation Health Plan of the Northwest 28 Section 5( b)
Surgical procedures (continued) You pay -Standard Option You pay -High Option
Voluntary sterilization (e. g., Tubal ligation, Vasectomy)

Surgically implanted time-release contraceptives and intrauterine devices
(IUDs)
Other implanted time-release drugs
Note: In addition to the office visit copayment,
we charge the prescription drug copayment for
the drug or device.

Treatment of burns

$15 per office visit for
outpatient services

Nothing for inpatient
services

$10 per office visit for
outpatient services

Nothing for inpatient
services

Not covered:
Reversal of voluntary sterilization
All charges All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:

-the condition produced a major effect on the
member's appearance; and

-the condition can reasonably be expected to
be corrected by such surgery.

Surgery to correct a condition that existed at or from birth and is a significant deviation from

the common form or norm. Examples of
congenital anomalies are protruding ear
deformities, cleft lip, cleft palate, birthmarks,
webbed fingers, and webbed toes.

$15 per office visit for
outpatient services

Nothing for inpatient
services

$10 per office visit for
outpatient services

Nothing for inpatient
services

All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance
on the other breast;

-treatment of any physical complications, such
as lymphedemas; and

-breast prostheses and surgical bras and
replacements covered at no charge (see
Prosthetic devices).

Note: If you need a mastectomy, you may choose
to have the procedure performed on an inpatient
basis and remain in the hospital up to 48 hours
after the procedure.

Nothing Nothing

Reconstructive surgery --continued on next page 31.
31 Page 32 33
2003 Kaiser Foundation Health Plan of the Northwest 29 Section 5( b)
Reconstructive surgery (continued) You pay -Standard Option You pay -High Option
Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed

primarily to improve physical appearance
through change in bodily form

Surgeries related to sex transformation

All charges All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate, or severe functional malocclusion

Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures

Other surgical procedures that do not involve the teeth or their supporting structures

$15 per office visit for
outpatient services

Nothing for inpatient
services

$10 per office visit for
outpatient services

Nothing for inpatient
services

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal

membrane, gingiva, and alveolar bone)

All charges All charges 32.
32 Page 33 34
2003 Kaiser Foundation Health Plan of the Northwest 30 Section 5( b)
Organ/ tissue transplants You pay -Standard Option You pay -High Option
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem cell

support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia;
advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced
neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian cancer; and
testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine

with multiple organs such as the liver, stomach,
and pancreas

Note: We cover related medical and hospital
expenses of the donor when we cover your
transplant.

$15 per office visit for
outpatient services

Nothing for inpatient
services

$10 per office visit for
outpatient services

Nothing for inpatient
services

Not covered:
Donor screening tests and donor search expenses, except those performed for the

actual donor
Implants of non-human or artificial organs
Transplants not listed as covered

All charges All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Ambulatory surgical center
Office

Nothing Nothing 33.
33 Page 34 35
2003 Kaiser Foundation Health Plan of the Northwest 31 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the

professional charge (i. e., physicians, etc.) are covered in Section 5( a) or (b).

I M
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T

Benefit Description You pay
Inpatient hospital You pay -Standard Option You pay -High Option
Room and board, such as:
Ward, semiprivate, or intensive care accommodations

General nursing care
Meals and special diets
NOTE: Your physician may prescribe private
accommodations or private duty nursing care if it
is medically necessary. If you want a private
room when it is not medically necessary, you pay
the additional charge above the semiprivate
room rate.

Nothing Nothing

Inpatient hospital --continued on next page 34.
34 Page 35 36
2003 Kaiser Foundation Health Plan of the Northwest 32 Section 5( c)
Inpatient hospital (continued) You pay -Standard Option You pay -High Option
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma
Pre-surgical testing
Costs associated with blood donated by you for a scheduled covered surgery

Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services
Take-home items
Note: You may receive covered hospital services
for certain dental procedures if a Plan physician
determines you need to be hospitalized for reasons
unrelated to the dental procedure. The conditions
for which we will provide hospitalization include
hemophilia and heart disease. The need for
anesthesia, by itself, is not such a condition.

Nothing Nothing

Not covered:
Custodial care
Non-covered facilities
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care
Cord blood procurement and storage for possible future need or for a yet-to-be

determined member recipient
Any inpatient dental procedures

All charges All charges 35.
35 Page 36 37
2003 Kaiser Foundation Health Plan of the Northwest 33 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay -Standard Option You pay -High Option
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, and blood products
Blood and blood plasma
Costs associated with blood donated by you for a scheduled covered surgery

Dressings, casts, and sterile tray services
Medical supplies
Anesthetics and anesthesia service
Note: Your regular prescription drug copayment will
apply for prescriptions purchased at Plan pharmacies.

Nothing Nothing

Not covered:
Collection, processing, and storage of blood donated by donors designated by you or a family

member
Cord blood procurement and storage for possible future need of for a yet-to-be determined member

recipient

All charges All charges

Extended care benefits/ skilled nursing care facility benefits
Up to 100 days per calendar year when full-time
skilled nursing care is necessary and confinement
in a skilled nursing facility is medically
appropriate. We cover the following:

Room, board, and general nursing care
Prescribed drugs and their administration, biologicals, supplies, and equipment ordinarily

provided or arranged by the skilled nursing
facility

Nothing Nothing

Not covered:
Custodial care
Care in an intermediate care facility
Personal comfort items such as telephone or television

All charges All charges 36.
36 Page 37 38
2003 Kaiser Foundation Health Plan of the Northwest 34 Section 5( c)
Hospice care You pay -Standard Option You pay -High Option
Supportive and palliative care for a terminally
ill member:

You must reside in the service area
Services are provided in the home
Services are provided in a Plan approved hospice facility

Services include inpatient care, outpatient care,
and family counseling. A Plan physician must
certify that you have a terminal illness, with a life
expectancy of approximately six months or less.

Note: Hospice is a program for caring for the
terminally ill that emphasizes supportive
services, such as home care and pain control,
rather than curative care of the terminal illness.
A person who is terminally ill may elect to
receive hospice benefits. These palliative and
supportive services include nursing care, medical
social services, physician services, and short-term
inpatient care for pain control and acute and
chronic symptom management. We also provide
counseling and bereavement services for the
individual and family members, and therapy for
purposes of symptom control to enable the person
to continue life with as little disruption as
possible. If you make a hospice election, you are
not entitled to receive other health care services
that are related to the terminal illness. If you
have made a hospice election, you may revoke
that election at any time, and your standard health
benefits will be covered.

Nothing Nothing

Not covered:
Independent nursing
Homemaker services

All charges All charges

Ambulance
Local professional ambulance service when medically appropriate $75 per transport $75 per transport

Not covered:
Transports that we determine are not medically necessary
All charges All charges 37.
37 Page 38 39
2003 Kaiser Foundation Health Plan of the Northwest 35 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems
are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially life threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may
determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
If you have an emergency call 911. When the operator answers, stay on the phone and answer all questions.

Emergencies within our service area:
Emergency care is provided at Plan hospitals 24 hours a day, seven days a week. If you have a medical emergency, go
to the closest Plan hospital. If you reasonably believe you have a medical emergency condition and you cannot safely
go to a Plan hospital, call 911 or go to the nearest hospital. If an ambulance comes, tell the paramedics that the person
who needs help is a Kaiser Permanente member.

If you are admitted to a non-Plan facility, call the Patient Transfer Coordinator from Portland at 503/ 813-4540. From
all other areas dial 877/ 813-5993 and ask for the Patient Transfer Coordinator. You must notify the Plan as soon as is
reasonably possible. If you are hospitalized in a non-Plan facility and Plan physicians believe your care can be better
provided in a Plan facility, you will be transferred when medically feasible.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan facility
would result in death, disability, or significant jeopardy to your condition.

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of injury or
unforeseen illness.

If you need to be hospitalized, the Plan must be notified as soon as is reasonably possible. If a Plan physician believes
care can be better provided in a Plan hospital, we will transfer you when medically feasible.

You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you
are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local telephone book under
Kaiser Permanente. These numbers are available 24 hours a day, seven days a week. You may also obtain information
about the location of facilities by calling the Membership Services department from Portland at 503/ 813-2000, or from
other areas call 800/ 813-2000 or our TTY numbers in Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388.

Emergency within our service area --begins on next page 38.
38 Page 39 40
2003 Kaiser Foundation Health Plan of the Northwest 36 Section 5( d)
Benefit Description You pay
Emergency within our service area You pay -Standard Option You pay -High Option
Emergency care as an outpatient or inpatient at a
hospital, including physicians'services

At a physician's office $15 per visit $10 per visit
At a Plan urgent care center $15 per visit $10 per visit
In a Plan hospital emergency room $75 per visit $75 per visit
Note: We waive your copayment if you are
admitted to a Plan hospital.

Emergency care in a non-Plan hospital
emergency room or urgent care center
$75 per visit $75 per visit

Not covered:
Elective care or non-emergency care
All charges All charges

Emergency outside our service area
Emergency care as an outpatient or inpatient at a
hospital, including physicians'services

At a physician's office $15 per visit $10 per visit
At an urgent care center $15 per visit $10 per visit
In a hospital emergency room $75 per visit $75 per visit
In a Kaiser Foundation hospital in another Kaiser Foundation Health Plan service area The amount you would be charged if you were a

member in that service
area

The amount you
would be charged if
you were a member
in that service area

Note: We waive your copayment if you are
admitted to a hospital.

Note: See the Travel Benefit for coverage of
continuing or follow-up care.

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been

foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside

the service area

All charges All charges 39.
39 Page 40 41
2003 Kaiser Foundation Health Plan of the Northwest 37 Section 5( d)
Ambulance You pay -Standard Option You pay -High Option
Professional ambulance service, including air
ambulance, when medically appropriate. See
Section 5( c) for non-emergency service.

$75 per transport $75 per transport

Not covered:
Transports we determine are not medically necessary
All charges All charges 40.
40 Page 41 42
2003 Kaiser Foundation Health Plan of the Northwest 38 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.

condition.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits You pay -Standard Option You pay -High Option

We cover all diagnostic and treatment services
recommended by a Plan provider and contained in
a treatment plan. The treatment plan may include
services, drugs and supplies described elsewhere in
this brochure.

Note: We cover the services only when we
determine that the care is clinically appropriate to
treat your condition, and only when you receive the
care as part of a treatment plan developed by a Plan
provider.

Note: OPM will base its review of disputes about
treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us
to pay or provide one clinically appropriate
treatment in favor of another.

Your cost sharing
responsibilities are no
greater than for other
illnesses or conditions

Mental health and substance abuse benefits --continued on next page 41.
41 Page 42 43
2003 Kaiser Foundation Health Plan of the Northwest 39 Section 5( e)
Mental health and substance abuse benefits (continued) You pay -Standard Option You pay -High Option
Diagnosis and treatment of psychiatric disorders,
mental illness or disorders of children, adolescents,
and adults. Services include:

Diagnostic evaluation
Treatment services (including individual and group therapy visits)

Crisis intervention and stabilization for acute episodes
Psychological testing necessary to determine the appropriate psychiatric treatment
Medication evaluation and management
Diagnosis and treatment of chemical dependency.
Services include:

Detoxification (medical management of withdrawal from the substance)

Treatment and counseling (including individual and group therapy visits)
Note: Your mental health or substance abuse
provider will develop a treatment plan to assist you
in improving or maintaining your condition and
functional level, or to prevent relapse.

Note: You may see a Plan outpatient mental health or
chemical dependency provider without a referral
from your primary care physician.

$15 per individual therapy
office visit

$7 per group therapy
office visit

$10 per individual
therapy office visit

$5 per group therapy
office visit

Inpatient psychiatric care
Inpatient care
Residential treatment
Note: All inpatient admissions and hospital
alternative services treatment programs require pre-approval
by a Plan physician.

Nothing Nothing

Intensive outpatient psychiatric treatment programs
Note: These services must be pre-approved by a Plan
physician.

$50 per day up to a
maximum of $250 per
episode or course of
treatment

$50 per day up to a
maximum of $250
per episode or course
of treatment

Mental health and substance abuse benefits --continued on next page 42.
42 Page 43 44
2003 Kaiser Foundation Health Plan of the Northwest 40 Section 5( e)
Mental health and substance abuse benefits (continued) You pay -Standard Option You pay -High Option
Not covered:
Care that is not clinically appropriate for the treatment of your condition

Services we have not approved
Intelligence, IQ, aptitude ability, or interest testing not necessary to determine the

appropriate treatment of a psychiatric condition
Evaluation or therapy on court order or as a condition of parole or probation, or otherwise

required by the criminal justice system, unless
determined by a Plan physician to be medically
necessary and appropriate

Services that are custodial in nature
Marital, family, or educational services
Services rendered or billed by a school or a member of its staff

Services provided under a federal, state, or local government program
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or
training regardless of diagnosis or symptoms that
may be present

All charges All charges

Limitation We may limit your benefits if you do not obtain a treatment plan. 43.
43 Page 44 45

2003 Kaiser Foundation Health Plan of the Northwest 41 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,

including with Medicare.

I M
P O
R T
A N
T

There are important features you should be aware of. These include:
Who can write your prescription. A Plan or referral physician, your primary care provider, or licensed dentist must write the prescription.

Where you can obtain them. You must fill the prescription at a Plan medical office pharmacy, or through our mail order program.
You may also obtain your prescriptions online, using our Members Only Web-site, www. kponline. org. This
site requires online registration. You can choose to have your prescriptions mailed to your home or to a Plan
medical office pharmacy for you to pick up. Online prescription orders must be paid for in advance, by a credit
card. Members may receive a 90-day supply of maintenance medications for one copayment, when purchased
through the mail order/ online prescription benefit.

We use a formulary. A formulary is a listing of preferred pharmaceutical substances and formulas. A team of Kaiser Permanente physicians and pharmacists independently and objectively evaluates the scientific literature

to identify the FDA-approved drugs best suited to treat specific medical conditions. These preferred drugs are
included on our formulary. If your physician feels that a non-formulary drug is the most appropriate therapy to
meet your individual medical needs, your physician may make an exception based on one of the following:

1. You are intolerant of formulary alternatives.
2. You have experienced treatment failure with formulary alternatives.
3. You are allergic to formulary alternatives.
4. You are a new member currently using a non-formulary drug. (A transition period is available while
new members switch to the formulary alternative.)
5. The non-formulary drug is for a dosage form or strength used in titrating a dose. (Titration is the process
of gradually shifting a patient from one dosage level to another.)

These are the dispensing limitations. We provide up to a 30-day supply. Maintenance medications may be obtained for up to a 90-day supply when ordered through our mail order/ online program.

Why use generic drugs? The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and name brand drugs must
meet the same standards for safety, purity, strength, and effectiveness. Generic drugs cost you and your plan
less money than a name-brand drug

When you have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to file a claim. For a covered out-of-area emergency, you will need to file a claim when you receive drugs from a non-Plan

pharmacy.
Covered medications and supplies --begin on next page 44.
44 Page 45 46
2003 Kaiser Foundation Health Plan of the Northwest 42 Section 5( f)
Benefit Description You pay
Covered medications and supplies You pay -Standard Option You pay -High Option
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a
Plan pharmacy or through our mail order program:

Drugs for which a prescription is required by law
Oral contraceptive drugs
Insulin
Glucose test strips
Disposable needles and syringes for administration of covered prescribed medications

Note: The cost of any needles and syringes (not for
insulin) may be less than your copayment. If this is
the case, you are required to pay the cost of the
needles and syringes.

Smoking cessation drugs and medication, including prescribed nicotine gum and patches,

when used in conjunction with smoking cessation
programs

Chemotherapy
Certain over-the-counter medications prescribed by a Plan physician and listed on the Plan's formulary

as the most appropriate treatment for a particular
condition

Diaphragms and cervical caps
Drugs for foreign travel

$15 per prescription or
refill for generic drugs

$30 per prescription or
refill for brand-name drugs

$10 per prescription or
refill for generic drugs

$20 per prescription or
refill for brand-name
drugs

Intrauterine devices (IUDs)
Implanted time-release contraceptive drugs
Other implanted time-release drugs
Note: We do not refund any portion of the copayment
if you request removal of the implanted device or
time-release medication before the end of its
expected life.

$15 for generic drugs or
$30 for brand-name drugs
times the number of
months the device or
medication is expected to
be effective, or 50% of our
allowance, whichever is
less up to $200

$10 for generic drugs
or $20 for brand-name
drugs times the
number of months the
device or medication
is expected to be
effective, or 50% of
our allowance,
whichever is less up to
$200

Injectable contraceptive drugs $15 for generic drugs or $30 for brand-name drugs
times the number of
months the medication is
expected to be effective

$10 for generic drugs
or $20 for brand-name
drugs times the number
of months the
medication is expected
to be effective

Covered medications and supplies --continued on next page 45.
45 Page 46 47
2003 Kaiser Foundation Health Plan of the Northwest 43 Section 5( f)
Covered medications and supplies (continued) You pay -Standard Option You pay -High Option
Diabetic supplies such as external insulin pumps, infusion devices, glucose monitors, and diabetic
foot care appliances
Drugs to treat sexual dysfunction.
Note: These drugs have dispensing limitations.
Contact the Plan for details.

50% of our allowance 50% of our allowance

Amino acid modified products used in the treatment of inborn errors of amino acid
metabolism (PKU)
Immunosuppressive drugs required after a transplant

Intravenous fluids and medication for home

Nothing Nothing

Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent

available, except those listed on the Plan's
formulary and prescribed by a Plan physician

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Vitamins and nutritional supplements that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs used in the diagnosis and treatment of infertility

Drugs related to non-covered services
Drugs used for weight management
Any packaging other than the dispensing pharmacy's standard packaging

Replacement of lost, stolen, or damaged drugs and accessories

All charges All charges 46.
46 Page 47 48
2003 Kaiser Foundation Health Plan of the Northwest 44 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call from Portland at 503/ 813-2000, or from other areas call 800/ 813-2000 or our
TTY numbers in Oregon at 800/ 735-2900 and in Washington at
800/ 833-6388, and talk with a registered nurse who will discuss treatment
options and answer your health questions.

Services for deaf and hearing
impaired

We provide TTY/ text telephone numbers -in Oregon at 800/ 735-2900 and in
Washington at 800/ 833-6388. Sign language services are also available.

Language interpretation Interpreters are available to assist non-English speaking members. Please see the listing in your Medical Directory.
High risk pregnancies Starring Healthy Babies was born August 1995 in response to the need for a comprehensive program to prevent pre-term birth. Our program works with
you to
Increase the gestational age of newborns and decrease our premature birth rate though prevention and education.

Decrease the length of stay our infants require in the Neonatal Intensive Care Unit due to premature birth.
Decrease the amount of time our high-risk mothers need to spend in the hospital during their pregnancies by helping with their care at home.
All pregnant Kaiser Permanente members are screened at their prenatal
appointments or at an urgent hospital visit. We enroll those identified as being
high risk for pre-term labor and assign them to their own case manager. 47.
47 Page 48 49
2003 Kaiser Foundation Health Plan of the Northwest 45 Section 5( g)
Feature Description
Centers of Excellence The Centers of Excellence program began in Fall 1987. As new technologies proliferate and become the standard of care, Kaiser
Permanente refers members to contracted "centers of excellence" for
certain specialized medical procedures.

We have developed a network of Centers of Excellence for organ
transplantation, which consists of medical facilities that have met
stringent criteria for quality care in specific procedures. A national
clinical and administrative team has developed guidelines for site
selection, site visit protocol, volume and survival criteria for evaluation
and selection of facilities. The institutions have a record of positive
outcomes and exceptional standards of quality.

Travel benefit Kaiser Permanente's travel benefits for Federal employees provide you with outpatient follow-up or continuing medical care when you are
temporarily outside your home service area by more than 100 miles
and outside of any other Kaiser Permanente service area. These
benefits are in addition to your emergency and urgent care benefits and
include:

Outpatient follow-up care necessary to complete a course of treatment after a covered emergency. Services include removal of

stitches, a catheter, or a cast.
Outpatient continuing care for conditions diagnosed and treated within the previous 90 days by a Kaiser Permanente health care

provider or affiliated Plan provider. Services include dialysis and
prescription drug monitoring.

You pay $25 for each follow-up or continuing care office visit. This amount will be deducted from the payment we make to you.

Your benefit is limited to $1200 each calendar year.
For more information about this benefit call 800/ 813-2000.
File claims as shown on page 53.
The following are not included in your travel benefits coverage:

Non-emergency hospitalization
Infertility treatments
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Transplants
DME
Prescription drugs
Home health services 48.
48 Page 49 50
2003 Kaiser Foundation Health Plan of the Northwest 46 Section 5( g)
Feature Description
Services from other Kaiser Permanente

Plans

When you visit the service area of another Kaiser Permanente plan, you
are entitled to receive virtually all the benefits described in this brochure
(including our mail order prescription program) at any Kaiser Permanente
medical office or medical center. You will have to pay the copayments or
other charges imposed by the Plan you are visiting, with the exception of
mail order prescriptions which are administered by your home Plan. If the
Plan you are visiting has a benefit that differs from the benefits of this
Plan, you are not entitled to receive that benefit.

Some services covered by this Plan, such as artificial reproductive services
and the services of specialized rehabilitation facilities, will not be
available in other Kaiser Permanente service areas. If a benefit is limited
to a specific number of visits or days, you are entitled to receive only the
number of visits or days covered by this Plan.

If you are seeking routine, non-emergent, or non-urgent services, you
should call the Kaiser Permanente Membership Services department in
that service area and request an appointment. You may obtain routine
follow-up or continuing care from these Plans, even when you have
obtained the original services in the service area. If you require
emergency services as the result of unexpected or unforeseen illness that
requires immediate attention, you should go directly to the nearest Kaiser
Permanente facility to receive care.

At the time you register for services, you will be asked to pay the charges
required by the local Plan.

If you plan to travel to an area with another Kaiser Permanente plan, and
wish to obtain more information about the benefits available to you from
the Kaiser Permanente Plan, please call Membership Services at
503/ 813-2000 or 800/ 813-2000. 49.
49 Page 50 51
2003 Kaiser Foundation Health Plan of the Northwest 47 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures at a Plan hospital we designate subject to pre-authorization only when a non-dental physical impairment exists which makes hospitalization

necessary to safeguard the health of the patient. See Section 5( c) for inpatient hospital benefits.
We do not cover the dental procedure except as described below.

including with Medicare.
Note: You will have to pay $10 for each missed appointment, unless you notify the dental office
in advance.

I M
P O
R T
A N
T

Dental Benefits
Service You pay -Standard Option You pay -High Option
Members who have elected the High Option Plan
will receive a comprehensive range of dental
services as described below. All services must be
prescribed by Plan dentists and provided at Plan
dental offices.

Note: These benefits are not covered under the
standard option. Members covered under
Standard Option may use Kaiser Dental facilities
only as appointment access permits.

No benefit See below

Diagnostic services and preventive care
including:

Routine oral examinations
X-rays
Routine teeth cleaning and topical application of fluoride when prescribed by a Plan dentist,

but not more than two visits in any twelve-month
period

Prescribed space maintainers and habit appliances

All charges $10 per office visit

Dental benefits --continued on next page 50.
50 Page 51 52
2003 Kaiser Foundation Health Plan of the Northwest 48 Section 5( h)
Dental Benefits (continued)
Service You pay -Standard Option You pay -High Option
Basic Restorative Services including basic
restorative services resulting from accidental
injury as follows:

Amalgam (silver) restorations in posterior teeth and anterior teeth

Synthetic (plastic, resin and glass ionomer) restorations in all primary teeth, anterior teeth
and one-surface restorations of posterior
permanent teeth

Stainless steel or plastic crowns when amalgam or synthetic restorative materials are not

professionally appropriate
If a member requests a procedure or material in excess of that recommended by a Plan dentist, the

desired procedure or material may be provided
upon payment of charges that reflect the
additional value of providing the procedure or
material, only if a Plan dentist agrees to perform
the service

Major Restorative Services as follows:

Placement of crowns, inlays, bridge pontics, or other cast metal restoration when prescribed by a

Plan dentist
If a member requests a procedure or material in excess of that recommended by a Plan dentist, the

desired procedure or material may be provided
upon payment of charges that reflect the
additional value of providing the procedure or
material, only if a Plan dentist agrees to perform
the service

Note: We do not cover repair or replacement of
existing cast crowns, inlays, bridge pontics, or
other cast metal restorations less than five years
after the date of the most recent placement or
replacement.

All charges $10 per office visit plus
50% of our allowance

Oral Surgery Services as follows:
Diagnosis, evaluation, consultation, and treatment for removal of teeth (including local

anesthesia)
Minor surgical preparation of mouth for insertion of dentures

Surgical treatment normally performed by a dentist for minor pathological conditions
Dental benefits --continued on next page 51.
51 Page 52 53
2003 Kaiser Foundation Health Plan of the Northwest 49 Section 5( h)
Dental Benefits (continued)
Service You pay -Standard Option You pay -High Option
Periodontal Services as follows:
Diagnosis, evaluation, consultation, and treatment for diseases of tissues supporting the teeth

including all follow-up cleaning visits

All charges $10 per office visit plus
50% of our allowance

Endodontic Services as follows:
Diagnosis, evaluation, consultation, and treatment for root canal therapy

Removable Prosthetic Appliances and Services as
follows:

Diagnosis, evaluation, consultation, and treatment for removable prosthetic appliances, including

full or partial dentures, relines, and rebases
Note: If the removable appliance cannot be
satisfactorily repaired or adjusted, then we cover a
new prosthetic appliance as long as the existing
appliance is more than 5 years old.

Emergency or Urgent Care
Note: This copayment applies for emergency or
urgent dental care received from a Plan dentist at
Plan dental offices.

Note: All other applicable copayments apply.

All charges $25 per office visit

Out-of-Area Emergency Care
Note: The Plan pays up to $100 for emergency care
for relief of pain, acute infection, or hemorrhage, or
necessary treatment (including local anesthesia and
pre-medication) due to injury.

All charges All charges
exceeding $100

Prescription Drugs
Covered under Prescription Drug benefits

Nitrous Oxide
Adults and children over 12 years of age
Children 12 years of age and under

All charges
All charges
$15 per occurrence
Nothing

Nightguards All charges 10% of our allowance
Dental benefits --continued on next page 52.
52 Page 53 54
2003 Kaiser Foundation Health Plan of the Northwest 50 Section 5( h)
Dental Benefits (continued)
Service You pay -Standard Option You pay -High Option
Not covered:
Orthodontics
Dental treatment for problems of the jaw joint, including temporomandibular joint syndrome/

craniomandibular disorders; or other conditions
of the joint linking the jaw bone and skull, and of
the complex of muscles, nerves, and other tissues
related to that joint

Dental implants, including bone augmentation and the fixed or removable prosthetic devices

attached to or covering the implants; and all
services and materials relating to the placement
or removal of implants including, but not limited
to, diagnostic consultations, impressions, oral
surgery, and removal of implants for cleaning;
and dental services related to post-operative
conditions or complications arising from implants

Restorative or reconstructive services for congenital or developmental malformations

Full mouth reconstructions. This includes appliances, restoration, and procedures needed to
alter vertical dimension or occlusion, or in
conjunction with alteration of vertical dimension
or occlusion or for the purpose of splinting teeth
or correcting attrition or abrasion.

Cosmetic dental services, including replacement of cosmetic dental restoration

Restoration replacement. Clinically acceptable restorations or material will not be removed or
replaced with alternative materials unless a
pathological condition of the teeth exists

IV sedation
Genetic testing
Replacement of pre-fabricated, non-cast crowns, including stainless steel crowns, which have not

been placed by a Kaiser Permanente dentist
Replacement of any permanent removable appliances with new permanent removable or

fixed prosthetic appliances within 5 years of the
date the member receives the appliance
regardless of where the appliance was obtained

Replacement of any nightguards within 5 years of the date the member receives the appliance even

if prescribed by a dentist outside the Plan

All charges All charges 53.
53 Page 54 55
2003 Kaiser Foundation Health Plan of the Northwest 51 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim
about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket
maximums.

Classes to change your lifestyle and keep you healthy At Kaiser Permanente, we actively encourage you to share responsibility for your health care. Choices you make every
day, about what you eat and drink, whether you exercise or smoke, how you handle stress, or whether you wear a seat belt,
are tied directly to your health. They affect your chances of having a stroke or a heart attack, getting cancer, or being at risk
for handicapping injuries.

We have developed a wide range of health education and health promotion classes to help you stay healthy. You can learn
how to kick the smoking habit for good, effectively manage your weight, improve personal and family relationships, deal
more effectively with a chronic health problem, have a safe and healthy pregnancy, and much more. Descriptions of the
Nondieting weight management and Freedom from Cigarettes classes are shown below. Over 40 other classes are also
offered. Class fees begin as low as $3 per member for some classes.

Our classes are open to everyone, but we offer them at special reduced rates to our members. If you would like to enroll,
you must fill out a registration form. For the latest class catalog, call:

Health Education Membership Services
Portland 503/ 286-6816 Portland 503/ 813-2000
8 am 5 pm, Monday-Friday 8 am 6 pm, Monday-Friday
Salem 503/ 316-2344 All other areas 800/ 813-2000
Washington 360/ 604-2070 8 am 6 pm, Monday-Friday

Nondieting Weight Management Healthy Weight Kit is an interactive guide to health weight management. It includes a resource guide, workbook, and
more!
Healthy Weight Kit Class is a 5-week program using the Healthy Weight Kit.
Freedom from Diets is a 12-week program led by dieticians. It is a lifestyle approach to weight management, developed by
Kaiser Permanente researchers.

Freedom from Cigarettes The "cold turkey" approach to stop smoking or chewing tobacco. Learn the latest and most effective techniques for kicking
the smoking habit for good. Sessions include:

Relaxation techniques Understanding cigarette addiction
Practicing effective ways to remain a non-smoker
Freedom from Cigarettes with temporary drug therapy These classes are designed to provide you with techniques and support that will increase your chances for lifelong freedom
from tobacco. The participants must be appropriate for this Program:
Drug therapy has been proven to be most successful when used in conjunction with a behavior change program. The
medication treatment is a short-term aid for people committed to learning how to stop smoking or chewing, and who have
been unsuccessful with other methods.

Your present pharmacy benefit provides coverage for smoking cessation drugs, nicotine gum, and patches when used in
conjunction with this program.

Benefits on this page are not part of the FEHB contract. 54.
54 Page 55 56
2003 Kaiser Foundation Health Plan of the Northwest 52 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan physician determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.

We do not cover the following:

Care by non-Plan providers except for authorized referrals or emergencies (see Section 5( d)), services under the Travel Benefit (see Section 5( g)), and services received from other Kaiser Permanente plans (see

Section 5( g));
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs, or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;

Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive without charge while in active military service;
Services required for (a) obtaining or maintaining employment or participation in employee programs or (b) insurance or governmental licensing; or

Services provided or arranged by criminal justice institutions for members confined therein. 55.
55 Page 56 57
2003 Kaiser Foundation Health Plan of the Northwest 53 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or fill your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers or when you use the
travel benefit. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is
the process:

Medical, hospital, and drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form CMS-1500, Health Insurance Claim Form. Facilities will file on
the UB-92 form. For claims questions and assistance, call us from Portland at
503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY numbers in
Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388.

When you must file a claim such as for services you receive outside of the
Plan's service area please complete the Emergency Care Information (ECI)
form and submit it with the CMS-1500 or a claim form that includes the
information shown below. ECI forms may be obtained by calling us from
Portland at 503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY
numbers in Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388. Bills
and receipts should be itemized and show:

Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
Follow up services rendered out-of-area
A copy of the explanation of benefits, payments, or denial from any primary payer such as the Medicare Summary Notice (MSN); and

Receipts, if you paid for your services.
Submit your claims to: Claims Administration
Kaiser Foundation Health Plan of the Northwest
500 N. E. Multnomah, Suite 100
Portland, Oregon 97232-2099

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the
service, unless timely filing was prevented by administrative operations of
Government or legal incapacity, provided the claim was submitted as soon as
reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 56.
56 Page 57 58
2003 Kaiser Foundation Health Plan of the Northwest 54 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your
claim or request for services, drugs, or supplies including a request for pre-authorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Kaiser Foundation Health Plan of the Northwest, 500 N. E. Multnomah, Suite
100, Portland, Oregon 97232-2099; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our
request --go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information
was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, DC 20415-3620. 57.
57 Page 58 59
2003 Kaiser Foundation Health Plan of the Northwest 55 Section 8
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the review
request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of
reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the
suit against OPM in Federal court by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision.
This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits
in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us from
Portland at 503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY numbers in Oregon at
800/ 735-2900 and in Washington at 800/ 833-6388 and we will expedite our review; or

(b) We denied your initial request for care or pre-authorization/ prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 58.
58 Page 59 60
2003 Kaiser Foundation Health Plan of the Northwest 56 Section 10
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care
expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan is the primary payer; it pays benefits
first. The other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners'Guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance. After the
primary payer plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance. If we are the
secondary payer, and you received your services from Plan providers, we may
bill the primary carrier.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered

employment, you should be able to qualify for premium-free Part A
insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social

Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare+ Choice is the term used to describe the various health
plan choices available to Medicare beneficiaries. The information in the next
few pages shows how we coordinate benefits with Medicare, depending on the
type of Medicare managed care plan you have.

The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the
way most people get their Medicare Part A and Part B benefits now. You may
go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.

When you are enrolled in Original Medicare along with this Plan, you still need
to follow the rules in this brochure for us to cover your care. We will not waive
any of our copayments.

Claims process when you have the Original Medicare Plan --You probably
will never have to file a claim form when you have both our Plan and the
Original Medicare Plan. 59.
59 Page 60 61
2003 Kaiser Foundation Health Plan of the Northwest 57 Section 10
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and

we will then provide secondary benefits for covered charges. You will not
need to do anything. To find out if you need to do something to file your
claim, call us from Portland at 503/ 813-2000 or from other areas at
800/ 813-2000 or our TTY numbers in Oregon at 800/ 735-2900 and in
Washington at 800/ 833-6388.

(Primary payer chart --begins on next page.) 60.
60 Page 61 62
2003 Kaiser Foundation Health Plan of the Northwest 58 Section 10
The following chart illustrates whether the Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Are an active employee with the Federal government (including
when you or a family member are eligible for Medicare solely
because of a disability),

2) Are an annuitant, .
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or .

b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)
.

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, .
(for Part B
services)

.
(for other
services)

6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

.
(except for claims
related to Workers'
Compensation)

B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, .

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, .

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, .

C. When you or a covered family member have FEHB and

1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
.

b) Are an active employee, or .
c) Are a former spouse of an annuitant, or .
d) Are a former spouse of an active employee . 61.
61 Page 62 63

2003 Kaiser Foundation Health Plan of the Northwest 59 Section 10
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like
HMOs) in some areas of the country. In most Medicare managed care plans, you can
only go to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available
to you:

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan, known as Medicare+ Choice or Kaiser Permanente Senior

Advantage, and also remain enrolled in our FEHB Plan. There is no additional
premium to enroll in Senior Advantage. In this case, we waive or lower some of our
copayments and coinsurance for your FEHB and Medicare coverage. If you would
like information about our Medicare+ Choice plan, please call from Portland
503/ 813-2000 or from other areas 800/ 813-2000 or our TTY numbers in Oregon at
800/ 735-2900 and in Washington at 800/ 833-6388. Your Kaiser Permanente Senior
Advantage-FEHBP benefits that we lowered or waived are:

Primary and Specialty care visits such as physical exams, allergy testing and injections, respiratory therapy, radiation therapy, same-day outpatient surgery,

gynecological visits, hearing and vision exams, and manual manipulation of the
spine: $0

Dialysis: $0
Hospital care: $0
Durable medical equipment: $0
Family planning: $0
Home health care: $0
Hospice care: $0
House calls: $0
Medical social services: $0
Mental health and substance abuse: inpatient and outpatient services (residential/ day treatment does have a copayment): $0

Physical, occupational and speech therapy, and rehabilitation services: $0 Prosthetic and orthotic devices, ostomy, and urological supplies: $0
Reconstructive therapy: $0
Skilled Nursing Facility care: up to 100 days per benefit period: $0
Transplants: $0
Vision exams: $0
X-ray, lab tests, and other special procedures: $0

This Plan and another plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB
plan. We will still provide benefits when your Medicare managed care plan is
primary if you use our Plan providers, but we will not lower or waive any of our
copayments or coinsurance. If you enroll in a Medicare managed care plan, tell us.
We will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
Medicare managed care plan, eliminating your FEHB premium. (OPM does not
contribute to your Medicare managed care plan premium.) For information on 62.
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2003 Kaiser Foundation Health Plan of the Northwest 60 Section 10
suspending your FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next open season
unless you involuntarily lose coverage or move out of the Medicare managed care
service area.

If you enroll in Medicare Part B If you enroll in Medicare Part B, we require you to assign your Medicare Part B benefits to the Plan for its services.

If you do not enroll in Medicare Part A
or Part B

If you do not have one or both Parts of Medicare, you can still be covered under the
FEHB Program. We will not require you to enroll in Medicare Part B, and if you
cannot get premium-free Part A, we will not ask you to enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If
TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE
or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.

Workers' Compensation We do not cover services that:

you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency

determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or

similar laws
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can

suspend your FEHB coverage to enroll in one of these State programs, eliminating
your FEHB premium. For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program, generally
you may do so only at the next Open Season unless you involuntarily lose coverage
under the State program.

When other Government agencies
are responsible for your care

We do not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.

When others are responsible for injuries When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in
the settlement.

If you do not seek damages, you must agree to let us try. This is called subrogation.
If you need more information, contact us for our subrogation procedures. 63.
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2003 Kaiser Foundation Health Plan of the Northwest 61 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.
Copayment A copayment is a fixed amount of money you pay when you receive covered services.

Covered services Care we provide benefits for, as described in this brochure. Custodial care (1) Assistance with activities of daily living, for example, walking, getting in
and out of bed, dressing, feeding, toileting, and taking medicine. (2) Care that
can be performed safely and effectively by people who, in order to provide the
care, do not require medical licenses or certificates or the presence of a
supervising licensed nurse. Custodial care that lasts 90 days or more is
sometimes known as Long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.

Durable medical equipment Durable medical equipment (DME) is equipment that is intended for repeated use, medically necessary, primarily and customarily used to serve a medical
purpose, generally not useful to a person who is not ill or injured, designed for
prolonged use, appropriate for use in the home, and serves a specific therapeutic
purpose in the treatment of an illness or injury.

Experimental or investigational services We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The
primary source of evidence about health outcomes of any intervention is peer-reviewed
medical or dental literature. When the service or supply, including a
drug: (1) has not been approved by the FDA; or (2) is the subject of a new drug
or new device application on file with the FDA; or (3) is part of a Phase I or
Phase II clinical trial, as the experimental or research arm of a Phase III clinical
trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or
(4) is available as the result of a written protocol that evaluates the service's
safety, toxicity, or efficacy; or (5) is subject to the approval or review of an
Institutional Review Board; or (6) requires an informed consent that describes
the service as experimental or investigational; then this Plan considers that
service, supply, or drug to be experimental, and not covered by the Plan.

Group health coverage Health care benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or through
membership in an employee organization. Health care coverage may be insured
or indemnity coverage, self-insured or self-funded coverage, or coverage
through health maintenance organizations or other managed care plans. Health
care coverage purchased through membership in an organization is also "group
health coverage."

Medically necessary All benefits need to be medically necessary in order for them to be covered benefits. Generally, if your Plan physician provides the service in accord with
the terms of this brochure, it will be considered medically necessary. However,
some services are reviewed in advance of your receiving them to determine if 64.
64 Page 65 66
2003 Kaiser Foundation Health Plan of the Northwest 62 Section 10
they are medically necessary. When we review a service to determine if it is
medically necessary, a Plan physician will evaluate what would happen to you
if you do not receive the service. If not receiving the service would adversely
affect your health, it will be considered medically necessary. The services must
be a medically appropriate course of treatment for your condition. If they are
not medically necessary, we will not cover the services. In case of emergency
services, the services that you received will be evaluated to determine if they
were medically necessary.

Our allowance The amount we use to determine your coinsurance. When you receive services or supplies from Plan providers, it is the amount that we set for the services or
supplies if we were to charge for them. When you receive services from non-Plan
providers, we determine the amount that we believe is usual and customary
for the service or supply, and compare it to the charges. Our allowance is based
upon the reasonableness of the charges. If the charges exceed what we believe
is reasonable, you may be responsible for the excess over our allowance in
addition to your coinsurance.

Us/ We Us and we refer to Kaiser Foundation Health Plan of the Northwest.
You You refers to the enrollee and each covered family member. 65.
65 Page 66 67

2003 Kaiser Foundation Health Plan of the Northwest 63 Section 11
Section 11. FEHB facts
No pre-existing condition limitation We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information about enrolling
in the FEHB Program

See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures for other plans, and other materials you need to make
an informed decision about your FEHB coverage. These materials tell you:

When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

When your enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.

Types of coverage available for you and your family Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or retirement office authorizes
coverage for. Under certain circumstances, you may also continue coverage for
a disabled child 22 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period in which the child is
born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective on the first day of the pay
period that begins after your employing office receives your enrollment form;
benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member
is no longer eligible to receive health benefits, nor will we. Please tell us
immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child under age 22 marries or
turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person
may not be enrolled in or covered as a family member by another FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family
coverage in the Federal Employees Health Benefits (FEHB) Program, if you are
an employee subject to a court or administrative order requiring you to provide
health benefits for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a
health plan that provides full benefits in the area where your children live or
provide documentation to your employing office that you have obtained other
health benefits coverage for your children. If you do not do so, your employing
office will enroll you involuntarily as follows: 66.
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2003 Kaiser Foundation Health Plan of the Northwest 64 Section 11
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service
Benefit Plan's Basic Option,
If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will

change your enrollment to Self and Family in the same option of the same
plan; or

If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self

and Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic
Option.

As long as the court/ administrative order is in effect, and you have at least one
child identified in the order who is still eligible under the FEHB Program, you
cannot cancel your enrollment, change to Self Only, or change to a plan that
doesn't serve the area in which your children live, unless you provide
documentation that you have other coverage for the children. If the
court/ administrative order is still in effect when you retire, and you have at least
one child still eligible for FEHB coverage, you must continue your FEHB
coverage into retirement (if eligible) and cannot make any changes after
retirement. Contact you employing office for further information.

When benefits and premiums start The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay
period that starts on or after January 1. Annuitants' coverage and premiums
begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for
other forms of coverage, such as temporary continuation of coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is the case even
when the court has ordered your former spouse to supply health coverage to
you. But, you may be eligible for your own FEHB coverage under the spouse
equity law or Temporary Continuation of Coverage (TCC). If you are recently
divorced or are anticipating a divorce, contact your ex-spouse's employing or
retirement office to get RI 70-5, the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees, or other information about your coverage choices. You can also
download the guide from OPM's website, www. opm. gov/ insure. 67.
67 Page 68 69

2003 Kaiser Foundation Health Plan of the Northwest 65 Section 11
Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of
Coverage (TCC). For example, you can receive TCC if you are not able to
continue your FEHB enrollment after you retire, if you lose your job, if you are
a covered dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross
misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary

Continuation of Coverage and Former Spouse Enrollees, from your employing
or retirement office or from www. opm. gov/ insure. It explains what you have to
do to enroll.

Converting to Individual Coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends (if you canceled your coverage or did not pay your premium, you cannot convert);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days after you receive
this notice. However, if you are a family member who is losing coverage, the
employing or retirement office will not notify you. You must apply in writing
to us within 31 days after you are no longer eligible for coverage. Conversion
to an individual dental plan is not available.

Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we will
not impose a waiting period or limit your coverage due to pre-existing
conditions.

Getting a Certificate of Group HealthPlan Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that offers limited Federal protections for health coverage

availability and continuity to people who lose employer group coverage. If you
leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods, limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate
from those plans. For more information, get OPM pamphlet RI 79-27,
Temporary Continuation of Coverage (TCC) under the FEHB Program. See
also the FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked questions. These highlight HIPAA rules, such as the
requirement that Federal employees must exhaust any TCC eligibility as one
condition for guaranteed access to individual health coverage under HIPAA,
and have information about Federal and State agencies you can contact for more
information. 68.
68 Page 69 70

2003 Kaiser Foundation Health Plan of the Northwest 66 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health during
Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you
may need due to a severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or Web-site listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 800/ LTC-FEDS (800/ 582-3337) (TDD for the hearing impaired:
800/ 843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 69.
69 Page 70 71
2003 Kaiser Foundation Health Plan of the Northwest 67 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 48 Allergy Care 19
Alternative treatment 26 Ambulance 9, 31, 34, 37
Anesthesia 30 Autologous bone marrow transplant
20, 30
Biopsy 27 Blood and blood plasma 33

Breast cancer screening 16
Casts 32, 33 Centers of Excellence 45

Changes for 2003 9 Chemotherapy 20
Chiropractic 26 Cholesterol tests 16
Coinsurance 61 Colorectal cancer screening 16
Congenital anomalies 27, 28 Contraceptive devices and drugs
9, 18, 28, 42 Coordination of benefits 56
Covered providers 10
Deaf and hearing impaired service 44 Deductible 13, 61

Dental care 47, 48, 49, 50 Diagnostic services 15
Disputed claims review 54 Donor expenses (transplants) 30
Dressings 32 Durable medical equipment (DME)
25, 61
Educational classes and programs 51 Effective date of enrollment 64

Emergency 35, 36, 37 Experimental or investigational 61
Eyeglasses 22
Family planning 18 Fecal occult blood test 16

Flexible benefits options 44
General exclusions 52
Hearing services 21 Home health services 25

Hospice care 34 Hospital 31

Immunizations 17 Infertility 19
Inpatient hospital benefits 31 Insulin 42

Laboratory and pathological services 16, 26
Magnetic resonance imagings (MRIs) 16, 26
Mail order prescription drugs 41 Mammograms 16
Maternity benefits 18 Medicaid 60
Medically necessary 61 Medicare 56
Mental conditions/ substance abuse benefits 38

Newborn care 15 Non-FEHB benefits 51
Nursery charges 18
Obstetrical care 18 Occupational therapy 20

Oral and maxillofacial surgery 29 Orthopedic devices 23
Out-of-pocket expenses 13 Oxygen 25, 32

Pap test 16 Physical examination 15
Physical therapy 20 Prescription drugs 41, 42, 43
Preventive care, adult 16 Preventive care, children 17
Preventive services 16 Prior approval 12
Prostate cancer screening 16 Prosthetic devices 23
Psychotherapy 40
Radiation therapy 20 Renal dialysis 20

Room and board 31
Second surgical opinion 15 Services from other Kaiser

Permanente Plans 46 Skilled nursing facility care 33
Smoking cessation 42, 51 Speech therapy 21
Splints 32 Sterilization procedures 28
Subrogation 60 Substance abuse 38
Surgery 27 . Anesthesia 30
. Oral 29 . Outpatient 31, 33
. Reconstructive 28

Syringes 42
Temporary continuation of coverage 65

Transplants 30, 43 Travel benefit 45
Treatment therapies 20
Vision services 21, 22, 23
Well child care 17 Workers' compensation 60

X-rays 16
24 hour nurse line 44 70.
70 Page 71 72
2003 Kaiser Foundation Health Plan of the Northwest 68 Summary
Summary of benefits for Kaiser Foundation Health Plan of the Northwest Standard Option 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. $15 per office visit 15

Services provided by a hospital:
Inpatient...............................................................................................
Outpatient ............................................................................................
Nothing
Nothing
31
33

Emergency benefits:
In-area..................................................................................................
Out-of-area ..........................................................................................
$75 per visit
$75 per visit
36
36

Mental health and substance abuse treatment: ......................................... Regular cost sharing 38
Prescription drugs................................................................................ $15 per prescription or refill for generic drugs

$30 per prescription or refill for
brand-name drugs

Dental Care ............................................................................................... No current benefit NA
Vision Care ............................................................................................... Refractions; $15 per office visit 21
Special features: Flexible benefits option; 24 hour nurse line; Services for deaf and hearing impaired;
Language interpretation; High risk pregnancies; Centers of Excellence; Travel benefit; Services from other
Kaiser Permanente Plans

Protection against catastrophic costs
(your catastrophic protection out-of-pocket maximum) ...........................
Nothing after $600/ Self Only or
$1,200/ Family enrollment per
year

Some costs do not count toward
this protection

13 71.
71 Page 72 73
2003 Kaiser Foundation Health Plan of the Northwest 69 Summary
Summary of benefits for Kaiser Foundation Health Plan of the Northwest High Option 2003
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.

$20 per prescription or refill for
brand-name drugs

Dental Care ............................................................................................... Various copayments based on
procedure rendered
47

Vision Care ............................................................................................... Refractions; $10 per office visit 21
Special features: Flexible benefits option; 24 hour nurse line; Services for deaf and hearing impaired;
Language interpretation; High risk pregnancies; Centers of Excellence; Travel benefit; Services from other
Kaiser Permanente Plans

Protection against catastrophic costs
(your catastrophic protection out-of-pocket maximum) ...........................
Nothing after $600/ Self Only or
$1,200/ Family enrollment per
year

Some costs do not count toward
this protection

13 72.
72 Page 73 74
2003 Kaiser Foundation Health Plan of the Northwest 70
Notes 73.
73 Page 74
2003 Rate Information for
Kaiser Foundation Health Plan of the Northwest

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and a special
FEHB guide is published for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of
any postal employee organization who are not career postal employees. Refer to the applicable
FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share

High Option
Self Only 571 $109.30 $44.00 $236.82 $95.33 $129.03 $24.27

High Option
Self and Family 572 $249.62 $102.19 $540.84 $221.42 $294.70 $57.11

Standard Option
Self Only 574 $102.80 $34.26 $222.72 $74.24 $121.64 $15.42

Standard Option
Self and Family 575 $235.93 $78.64 $511.18 $170.39 $279.18 $35.39 74.

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