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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2026-12/31/2026 : CIS Trust - Trad Coverage for: Individual / Family I Plan Type: EPO All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see or call 1-[PHONE REDACTED] (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-[PHONE REDACTED] (TTY: 711) to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? Not Applicable. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $1,500 Individual / $3,000 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, health care this plan doesn’t cover, and services indicated in chart starting on page 2. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See www.kp.org or call 1-[PHONE REDACTED] (TTY: 711) for a list of Participating Providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? Yes, but you may self-refer to certain specialists. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. Group ID: 20538 Subgroup ID: 00 SBC ID:17573 1 of 6 ---PAGE BREAK--- All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Limitations, Exceptions & Other Important Information If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness $20 / visit Not covered $5 / visit for the first 3 outpatient visits combined for primary care, mental/behavioral health, substance abuse services, and other qualified visits. Specialist visit $30 / visit Not covered None Preventive care/ screening/ immunization No charge Not covered You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test ray, blood work) Xray: $20 / visit. Lab tests: $20 / visit. Not covered None Imaging (CT/PET scans, MRI's) $50 / visit Not covered Some services may require prior authorization. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.kp.org/formulary Generic drugs $10 (retail) & $20 (mail order) / prescription. Not covered Up to a 30-day supply (retail) & up to a 90-day supply (mail order). Subject to formulary guidelines. Preferred brand drugs $20 (retail) & $40 (mail order) / prescription. Not covered Up to a 30-day supply (retail) & up to a 90-day supply (mail order). Subject to formulary guidelines. Non-preferred drugs $40 (retail) & $80 (mail order) / prescription. Not covered Up to a 30-day supply (retail) & up to a 90-day supply (mail order). Subject to formulary guidelines, when approved through exception process. Specialty drugs $40 (retail) / prescription Not covered Up to a 30-day supply (retail). Subject to formulary guidelines, when approved through exception process. 2 of 6 ---PAGE BREAK--- Common Medical Event Services You May Need What You Will Pay Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Limitations, Exceptions & Other Important Information If you have outpatient surgery Facility fee ambulatory surgery center) $50 / visit Not covered Prior authorization required. Physician/surgeon fees No charge Not covered Physician/surgeon fees are included in the Facility fee. If you need immediate medical attention Emergency room care $200 / visit $200 / visit Copayment waived if admitted directly to the hospital as an inpatient. Emergency medical transportation $75 / trip $75 / trip None Urgent care $40 / visit Not covered Non-participating providers covered when temporarily outside the service area. $40 / visit If you have a hospital stay Facility fee hospital room) $200 / day up to $1,000 / admission. Not covered Prior authorization required. Physician/surgeon fee No charge Not covered Physician/surgeon fees are included in the Facility fee. If you need mental health, behavioral health, or substance abuse services Outpatient services $20 / visit Not covered $5 / visit for the first 3 outpatient visits combined for primary care, mental/behavioral health, substance abuse services, and other qualified visits. Inpatient services $200 / day up to $1,000 / admission. Not covered Prior authorization required. If you are pregnant Office visits No charge Not covered Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC ultrasound). Childbirth/delivery professional services No charge Not covered Professional services are included in the facility fee. Childbirth/delivery facility services $200 / day up to $1,000 / admission. Not covered Prior authorization required. 3 of 6 ---PAGE BREAK--- Common Medical Event Services You May Need What You Will Pay Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Limitations, Exceptions & Other Important Information If you need help recovering or have other special health needs Home health care No charge Not covered 130 visit limit / year. Prior authorization required. Rehabilitation services Outpatient: $30 / visit Inpatient: $200 / day up to $1,000 / admission. Not covered Outpatient: 20 visit limit / year. Prior authorization required. Inpatient: Prior authorization required. Habilitation services $30 / visit Not covered 20 visit limit / year. Prior authorization required. Skilled nursing care No charge Not covered 100 day limit / year. Prior authorization required. Durable medical equipment 20% coinsurance Not covered Subject to formulary guidelines. Prior authorization required. Hospice service No charge Not covered Prior authorization required. If your child needs dental or eye care Children's eye exam No charge for refractive exam Not covered None Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) ●Acupuncture ●Children's glasses ●Chiropractic care ●Cosmetic surgery ●Dental care (Adult & Child) ●Long-term care ●Non-emergency care when traveling outside the U.S. ●Private-duty nursing ●Routine foot care ●Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) ●Bariatric surgery ●Hearing aids (Under age 26: 1 aid / ear / 36 months) ●Infertility treatment ●Routine eye care (Adult) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-[PHONE REDACTED]. 4 of 6 ---PAGE BREAK--- Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the agencies in the chart below. Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Kaiser Permanente Member Services 1-[PHONE REDACTED] (TTY: 711) or www.kp.org/memberservices Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-[PHONE REDACTED] x61565 or www.cciio.cms.gov Oregon Department of Insurance 1-[PHONE REDACTED] or Washington Department of Insurance 1-[PHONE REDACTED] or www.insurance.wa.gov Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 1-[PHONE REDACTED] (TTY: 711) TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-[PHONE REDACTED] (TTY: 711) TRADITIONAL CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 1-[PHONE REDACTED] (TTY: 711) DUTCH (Deitsch): Fer Hilf griege in Deitsch, ruf 1-[PHONE REDACTED] (TTY: 711) uff NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-[PHONE REDACTED] (TTY: 711) SAMOAN (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 1-[PHONE REDACTED] (TTY: 711) CAROLINIAN (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 1-[PHONE REDACTED] (TTY: 711) CHAMORRO (Chamoru): Para un ma ayuda gi finu Chamoru, ȧ'gang 1-[PHONE REDACTED] (TTY: 711) To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 6 ---PAGE BREAK--- About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible Specialist copayment Hospital (facility) copayment Other (blood work) copayment $0 $30 $200 $20 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $0 Copayments $300 Coinsurance $0 What isn't covered Limits or exclusions $60 The total Peg would pay is $360 Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan's overall deductible Specialist copayment Hospital (facility) copayment Other (blood work) copayment $0 $30 $200 $20 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $0 Copayments $600 Coinsurance $10 What isn't covered Limits or exclusions $0 The total Joe would pay is $610 Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible Specialist copayment Hospital (facility) copayment Other (x-ray) copayment $0 $30 $200 $20 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $0 Copayments $600 Coinsurance $50 What isn't covered Limits or exclusions $0 The total Mia would pay is $650 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6 ---PAGE BREAK--- Nondiscrimination Notice Kaiser Foundation Health Plan of the Northwest (Kaiser Health Plan) complies with applicable federal and state civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin (including limited English proficiency), age, disability, or sex (including sex characteristics, intersex traits; pregnancy or related conditions; sexual orientation; gender identity, and sex stereotypes). Kaiser Health Plan: ■Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as: ●Qualified sign language interpreters ●Written information in other formats, such as large print, audio, braille, and accessible electronic formats ■Provide no cost language services to people whose primary language is not English, such as: ●Qualified interpreters ●Information written in other languages If you need these services, call Member Services at 1-[PHONE REDACTED] (TTY: 711). If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance with our Civil Rights Coordinator, by mail, phone, or fax. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You may contact our Civil Rights Coordinator at: Member Relations Department Attention: Kaiser Civil Rights Coordinator 500 NE Multnomah St., Suite 100 Portland, OR 97232-2099 Fax: 1-[PHONE REDACTED] You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201 Phone: 1-[PHONE REDACTED] TDD: 1-[PHONE REDACTED] Complaint forms are available at www.hhs.gov/ocr/office/file/index.html. NW_Commercial_ACA_1557_NDN NOA_2024 ---PAGE BREAK--- For Washington Members: You can also file a complaint with the Washington State Office of the Insurance Commissioner, electronically through the Office of the Insurance Commissioner Complaint portal, available at or by phone at 1-[PHONE REDACTED], or [PHONE REDACTED] (TDD). Complaint forms are available at This notice is available at NW_Commercial_ACA_1557_NDN NOA_2024 ---PAGE BREAK--- Help in Your Language ATTENTION: If you speak English, language assistance services including appropriate auxiliary aids and services, free of charge, are available to you. Call 1-[PHONE REDACTED](TTY: 711). አማርኛ (Amharic) ትኩረት፡ አማርኛ የሚናገሩ ከሆነ ተገቢ የሆኑ ረዳት መርጃዎችን እና አገልግሎቶችን ጨምሮ የቋንቋ እርዳታ አገልግሎቶች በነጻ ይገኛሉ። በ 1-[PHONE REDACTED] ይደውሉ (TTY: 711)። العربية (Arabic) تنبيه: إذا كنت تتحدث ،العربية تتوفر لك خدمات المساعدة اللغوية بما في ذلك من وسائل المساعدة والخدمات المناسبة بالمجان .اتصل بالرقم 1-[PHONE REDACTED] ) TTY: 711 中文 (Chinese) 注意事項：如果您說中文，您可獲得免費語言協助服務，包括適當的輔助器材和服務。致電1-[PHONE REDACTED]（TTY：711）。 فارسی (Farsi) توجه: اگر به زبان فارسی صحبت می،کنيد» تسهيلات زبانی« ، از جمله کمک ها و خدمات پشتيبانی ،مناسب به صورت رايگان در دسترس تان است با1-[PHONE REDACTED] تماس بگيريد ) TTY )تلفن متنی 711 Français (French) ATTENTION : si vous parlez français, des services d'assistance linguistique comprenant des aides et services auxiliaires appropriés, gratuits, sont à votre disposition. Appelez le 1-[PHONE REDACTED] (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, steht Ihnen die Sprachassistenz mit Hilfsmitteln und Dienstleistungen kostenfrei zur Verfügung. Rufen Sie 1-[PHONE REDACTED] an (TTY: 711). 日本語 (Japanese) 注意：日本語を話す場合、適切な補助機器やサービスを含む言語支援サービスが無料で提供されます。1-[PHONE REDACTED] までお電話くだ さい（TTY: 711）。 ខ្មែរ (Khmer) យកចិត្តទុកដាក់៖ បបអ្នកិិយយខ្មែរ បេវាជំិួយភាសា រួមទាំងជំិួយិិងបេវាេមស្េប បដាយឥតគិតថ្លៃ មាិចំបោះ្នក។ បៅ 1-[PHONE REDACTED] (TTY: 711). 한국어 (Korean) 주의: 한국어를 구사하실 경우, 필요한 보조 기기 및 서비스가 포함된 언어 지원 서비스가 무료로 제공됩니다. 1-800-813-2000로 전화해 주 세요(TTY: 711). ລາວ (Laotian) ເອົາໃຈໃສ່: ຖ້າທ່ານເວົ້າພາສາລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ ລວມທັງອຸປະກອນ ແລະ ການບໍລິການຊ່ວຍເຫຼືອທີ່ເໝາະສົມ ຈະມີໃຫ້ທ່ານໂດຍບໍ່ເສຍຄ່າ. ໂທ 1-[PHONE REDACTED] (TTY: 711). Afaan Oromoo (Oromo) XIYYEEFFANNOO: Yoo Afaan Oromo dubbattu ta'e, Tajaajila gargaarsa afaanii, gargaarsota dabalataa fi tajaajiloota barbaachisoo kaffaltii irraa bilisa ta'an, isiniif ni jira. 1-[PHONE REDACTED] irratti bilbilaa (TTY፦ 711) ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਤੁਹਾਡੇ ਲਈ ਮੁਫ਼ਤ ਉਪਲਬਧ ਭਾਸ਼ਾ ਸਹਾਇਤਾ ਜਜਨ੍ਹਾਂ ਜਵੱਚ ਯੋਗ ਸਹਾਇਕ ਸਹਾਇਤਾਵਾਂ ਅਤੇ ਸੇਵਾਵਾਂ ਸ਼ਾਮਲ ਹਨ। ਕਾਲ ਕਰੋ 1-[PHONE REDACTED] (TTY፦ 711). Română (Romanian) ATENȚIE: Dacă vorbiți română, vă sunt disponibile gratuit servicii de asistență lingvistică, inclusiv ajutoare și servicii auxiliare adecvate. Sunați la 1-[PHONE REDACTED] (TTY: 711). Pусский (Russian) ВНИМАНИЕ! Если вы говорите по-русски, вам доступны бесплатные услуги языковой поддержки, включая соответствующие вспомогательные средства и услуги. Позвоните по номеру 1-[PHONE REDACTED] (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios de asistencia lingüística que incluyen ayudas y servicios auxiliares adecuados y gratuitos. Llame al 1-[PHONE REDACTED] (TTY: 711). NW_Commercial_ACA_1557_NDN NOA_2024 ---PAGE BREAK--- Tagalog (Tagalog) PAALALA: Kung nagsasalita ka ng Tagalog, available sa iyo ang serbisyo ng tulong sa wika kabilang ang mga naaangkop na karagdagang tulong at serbisyo, nang walang bayad. Tumawag sa 1-[PHONE REDACTED] (TTY: 711). ไทย (Thai) โปรดทราบ: หากท่านพูดภาษาไทย ท่านสามารถขอรับบริการช่วยเหลือด้านภาษา รวมทั้งเครื่องช่วยเหลือและบริการเสริมที่เหมาะสมได้ฟรี โทร 1-[PHONE REDACTED] (TTY: 711). Українська (Ukrainian) УВАГА! Якщо ви володієте українською мовою, вам доступні безкоштовні послуги з мовної допомоги, включно із відповідною додатковою допомогою та послугами. Зателефонуйте за номером 1 [PHONE REDACTED] (TTY: 711). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói tiếng Việt, bạn có thể sử dụng các dịch vụ hỗ trợ ngôn ngữ miễn phí, bao gồm các dịch vụ và phương tiện hỗ trợ phù hợp. Xin gọi 1-[PHONE REDACTED] (TTY: 711). NW_Commercial_ACA_1557_NDN NOA_2024