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…of Benefits, and Reductions ………………………………………………………………………. 60 Exclusions …………………………………………………………………………………………………………………………………………………. 60 Limitations ………………………………………………………………………………………………………………………………………………… 63 Coordination of Benefits ……………………………………………………………………………………………………………………………… 63 Reductions …………………………………………………………………………………………………………………………………………………. 64 Post-Service Claims and Appeals ……………………………………………………………………………………………………………………… 66 Who May File…………………………………………………………………………………………………………………………………………….. 66……

...companies, coverages, rights or complaints at: 1-800-252-3439 You may write the Texas Department of Insurance, P.O. Box 149104, Austin, TX 78714-9104, Fax No. (512) 475-1771. Claim Disputes: Should you have……

…12.00% 32 25.00% 20.00% 15.00% 12.00% 33 25.00% 20.00% 15.00% 12.00% 34 25.00% 20.00% 15.00% 12.00% 35 25.00% 20.00% 15.00% 10.00% 36 25.00% 20.00% 15.00% 10.00% 37 25.00% 20.00% 15.00%……

…of Premium Payment………………………………………………………………………………………… 4 Computation of Premium…………………………………………………………………………………………………… 4 Premiums for Changes in Insurance …………………………………………………………………………………… 4 Right to Change Premium Rates………………………………………………………………………………………… 5 GRACE PERIOD…………………………………………………………………………………………………………………………. 6 END OF INSURANCE PROVIDED BY THIS……

…29 Hospice Services …………………………………………………………………………………………………………………………………….. 29 Infertility Services …………………………………………………………………………………………………………………………………… 30 Infertility Services Exclusions …………………………………………………………………………………………………………… 30 Limited Dental Services………………………………………………………………………………………………………………………….. 30 Covered Dental Services ………………………………………………………………………………………………………………….. 30 Limited Dental Services Exclusions …………………………………………………………………………………………………. 31 Limited……

…Appealing Denials of Claims for Benefits ………………………………………………………………………. 83 Legal Action ………………………………………………………………………………………………………………….. 84 Plan Administration ………………………………………………………………………………………………. 86 Plan and Contact Information …………………………………………………………………………………………. 86 Type of Plan ………………………………………………………………………………………………………………. 86 Plan Sponsor ……………………………………………………………………………………………………………………

…Appealing Denials of Claims for Benefits ………………………………………………………………………. 83 Legal Action ………………………………………………………………………………………………………………….. 84 Plan Administration ………………………………………………………………………………………………. 86 Plan and Contact Information …………………………………………………………………………………………. 86 Type of Plan ………………………………………………………………………………………………………………. 86 Plan Sponsor ……………………………………………………………………………………………………………………

…BENEFIT: AIR BAG USE ………………………………………………………………………………………….. 76 ADDITIONAL BENEFIT: CHILD CARE …………………………………………………………………………………………… 77 ADDITIONAL BENEFIT: CHILD EDUCATION…………………………………………………………………………………. 78 ADDITIONAL BENEFIT: SPOUSE EDUCATION …………………………………………………………………………….. 79 ADDITIONAL BENEFIT: REPATRIATION EXPENSE ………………………………………………………………………. 80 ADDITIONAL……

…BENEFIT: AIR BAG USE ………………………………………………………………………………………….. 76 ADDITIONAL BENEFIT: CHILD CARE …………………………………………………………………………………………… 77 ADDITIONAL BENEFIT: CHILD EDUCATION…………………………………………………………………………………. 78 ADDITIONAL BENEFIT: SPOUSE EDUCATION …………………………………………………………………………….. 79 ADDITIONAL BENEFIT: REPATRIATION EXPENSE ………………………………………………………………………. 80 ADDITIONAL……

…73 Coordinating Benefits With Other Programs ……………………………………………………………… 74 How Coordination of Benefits Works ………………………………………………………………………………. 74 Group Health Plans …………………………………………………………………………………………………….. 75 HMOs ……………………………………………………………………………………………………………………….. 76 Medicare ………………………………………………………………………………………………………………….. 76 TRICARE ……………………………………………………………………………………………………………………. 78 Medicaid……

………………………………………………………………………………………………………….. 67 Step Therapy …………………………………………………………………………………………………………….. 68 Diabetes Supplies and Insulin …………………………………………………………………………………………. 68 What’s a Covered Expense …………………………………………………………………………………………….. 68 Quantity Limits ………………………………………………………………………………………………………….. 69 What’s Not Covered ………………………………………………………………………………………………………. 69 Prescription Drug Savings……

………………………………………………………………………………………………………….. 70 Step Therapy …………………………………………………………………………………………………………….. 71 Diabetes Supplies and Insulin …………………………………………………………………………………………. 71 Group Health Program Booklet (HPN) iii What’s a Covered Expense …………………………………………………………………………………………….. 71 Quantity Limits ………………………………………………………………………………………………………….. 72 What’s Not……

………………………………………………………………………………………………………………… 53 Vision Care Discounts …………………………………………………………………………………………………….. 54 Group Health Program Booklet ii Blue Access for MembersSM ……………………………………………………………………………………………. 54 Get the App ………………………………………………………………………………………………………………. 54 Take Advantage of Discounts ………………………………………………………………………………………. 54 Your……

…beneficiaries receiving payment ………………………………………………………………………… . b For terminated vested participants ……………………………………………………………………………………………………………. c For active participants …………………………………………………………………………………………………………………………….. d Total ……………………………………………………………………………………………………………………………………………………. 4 If the plan is in at-risk status, check the box……

………………………………………………………………………………………………………….84 Provider Directory …………………………………………………………………………………………………………………………………………84 Online Tools and Resources ……………………………………………………………………………………………………………………………84 Document Delivery Preferences ………………………………………………………………………………………………………………………84 How to Reach Us …………………………………………………………………………………………………………………………………………..84 Payment Responsibility ………………………………………………………………………………………………………………………………….86 Group ID: 232413 Kaiser Permanente Deductible HMO Plan Contract:……

…Condition Limitation ……………………………………………………………………………………………………………………… 21 EXCLUSIONS ………………………………………………………………………………………………………………………………………………….. 22 GENERAL PROVISIONS …………………………………………………………………………………………………………………………………… 22 DEFINITIONS …………………………………………………………………………………………………………………………………………………… 26 ERISA ……………………………………………………………………………………………………………………………………………………………… 31 16 SCHEDULE OF INSURANCE The Policy of long term Disability insurance provides You……

...Formats ……………………………………………………………………………………………………….83 Provider Directory …………………………………………………………………………………………………………………………………………83 Online Tools and Resources ……………………………………………………………………………………………………………………………83 Document Delivery Preferences ………………………………………………………………………………………………………………………83 How to Reach Us …………………………………………………………………………………………………………………………………………..84 Payment Responsibility ………………………………………………………………………………………………………………………………….85 Group ID: 232413 Kaiser Permanente HSA-Qualified High Deductible……

…Condition Limitation ……………………………………………………………………………………………………………………… 21 EXCLUSIONS ………………………………………………………………………………………………………………………………………………….. 22 GENERAL PROVISIONS …………………………………………………………………………………………………………………………………… 22 DEFINITIONS …………………………………………………………………………………………………………………………………………………… 26 ERISA ……………………………………………………………………………………………………………………………………………………………… 31 16 SCHEDULE OF INSURANCE The Policy of long term Disability insurance provides You……

…Provider Directory …………………………………………………………………………………………………………………………………………84 Online Tools and Resources ……………………………………………………………………………………………………………………………84 Document Delivery Preferences ………………………………………………………………………………………………………………………84 How to Reach Us …………………………………………………………………………………………………………………………………………..84 Payment Responsibility ………………………………………………………………………………………………………………………………….85 Group ID: 604702 Kaiser Permanente HSA-Qualified High Deductible Health Plan……

…Online Tools and Resources ……………………………………………………………………………………………………………………………84 Document Delivery Preferences ………………………………………………………………………………………………………………………84 How to Reach Us …………………………………………………………………………………………………………………………………………..85 Payment Responsibility ………………………………………………………………………………………………………………………………….86 Group ID: 604702 Kaiser Permanente Deductible HMO Plan Contract: 1 Version: 18 EOC#……