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MK-43A Copay B: Alternative Care & Vision January 1, 2025 - December 31, 2025 Out-of-Pocket Maximum (Note: All Copayment, and Coinsurance amounts count toward the Out-of-Pocket Maximum, unless otherwise noted.) For one Member $1,500 For an entire Family $3,000 Office visits You pay Routine preventative physical exam $0 Telehealth (phone/video) Primary Care $5 for first 3 visits; then $20 for additional visits in the same Year * Specialty Care $30 Urgent Care $40 Tests (outpatient) You pay Preventive Tests $0 Laboratory $20 per department visit X-ray, imaging, and special diagnostic procedures $20 per department visit CT, MRI, PET scans $50 per department visit Medications (outpatient) You pay Prescription drugs (up to a 30 day supply) Generic $10, Preferred $20, Non-preferred $40, Specialty $40 (Per prescription) Mail Order Prescription drugs (up to a 90 day supply) 2 x Copay Administered medications, including injections (all outpatient settings) 20% Coinsurance Nurse treatment room visits to receive injections $10 Maternity Care You pay Scheduled prenatal care visits and postpartum visits $0 Laboratory $20 per department visit X-ray, imaging, and special diagnostic procedures $20 per department visit Inpatient Hospital Services $200 per day up to $1,000 per admission Hospital Services You pay Ambulance Services (per transport) $75 Emergency services $200 (Waived if admitted) Inpatient Hospital Services $200 per day up to $1,000 per admission Outpatient Services (other) You pay Outpatient surgery visit $50 Chemotherapy/radiation therapy visit $30 Durable medical equipment 20% Coinsurance Physical, speech, and occupational therapies (up to 20 visits per therapy per Calendar Year) $30 Skilled Nursing Facility Services You pay Inpatient skilled nursing Services (up to 100 days per Calendar Year) $0 Mental Health and Substance Use Disorder Services You pay Outpatient Services (Group visit ½ copay) $5 for first 3 visits; then $20 for additional visits in the same Year * Inpatient hospital & residential Services $200 per day up to $1,000 per admission Alternative Care** (self-referred) You pay ---PAGE BREAK--- MK-43A Acupuncture Services (up to 12 visits per year) $20 per visit Chiropractic Services (up to 20 visits per year) $20 per visit Massage Therapy (up to 12 visits per year) $25 per visit Naturopathic Medicine $5 for first 3 visits; then $20 for additional visits in the same Year * Vision Services You pay Routine eye exam (Covered until the end of the month in which Member turns 19 years of age) $0 Vision hardware and optical Services (Covered until the end of the month in which Member turns 19 years of age)** No charge for eyeglass lenses or frames or contact lenses every 12 months. Routine eye exam (For members 19 years and older) $20 Vision hardware and optical Services (For members 19 years and older)* Balance after $150 allowance, once every calendar year * First 3 visits (or days) are any combination of in-person or telemedicine Services for primary care non-specialty medical Services, mental health outpatient Services, naturopathic medicine, or Substance Use Disorder outpatient Services. Any amount you pay for covered Services does not count toward the Out-of-Pocket Maximum. kp.org Resources: Here are some ways to make managing your care easier: Sign on to our convenient online services and stay on top of your treatment from the comfort of your home. • Find or switch doctors • Schedule and cancel appointments • View lab test results • Health risk assessments • Exchange secure emails with your doctor and health care team • Order prescription refills • Find locations of our medical centers and offices Appointment Alternatives: -Advice Nurse Line - If you have a health concern but aren’t sure where to go for care, call the Kaiser Permanente advice nurse line at (800) 813-2000. Available 24 hours a day, our advice nurses can give you guidance on getting the care you need, view your medical record, and help schedule an appointment if needed. -Virtual Care - Virtual care options are available for many health concerns. You can skip a copay and schedule a visit to see a doctor using your computer or mobile device. Call (800) 813-2000 (toll free), (503) 813-2000, or 711 (TTY for the hearing/speech impaired). You can use online scheduling to make an appointment with our Urgent Care providers. We offer both same-day Urgent Care Telephone Appointments and Urgent Care Video Visits. -Email Your Doctor - You can send a secure email to your doctor and care team for answers to non-urgent health and wellness questions at any time by logging on to kp.org on your computer or mobile device. Disease Management: Our integrated health care delivery system provides comprehensive and coordinated care for our members with chronic conditions. All members who are identified by specified criteria are automatically enrolled in one of our disease management programs. Your personal physician, specialists, pharmacists, nurses, nutritionists, class instructors, and others will care for the whole you, body and mind. Healthy Lifestyle Programs: or Digital and telephonic health coaching programs are available at no cost to members. These personalized interactive programs can help a member’s goals to lose weight, eat better, manage stress, quit smoking, and more. The online healthy lifestyle programs include: • Balance® - A weight management program • Care for Pain® - For members living with chronic pain • Breathe® - A program to help you quit smoking (kp.org/quit smoking) • Care® for Depression – Help with managing depression • Care® for Your Back – Delivers personalized strategies for preventing and managing back pain • Care® for sleep – Tools for sleeping better • Care® for Diabetes – Tools for managing Diabetes • Relax® - Stress management Member Discounts: kp.org/choosehealthy Available to you at no cost through your health plan, ChooseHealthy™offers a directory of complementary care providers, an online store, fitness club discounts, savings on health products and services, and more. You'll find reduced rates on: • Fitness facility memberships • Chiropractic care • Health & fitness books & videos • Massage therapy services • Acupuncture • Herbs, vitamins, and supplements Plan is subject to exclusions and limitations. A complete list of the exclusions and limitations is included in the Evidence of Coverage (EOC). EOCs are available upon request or you may go to kp.org/plandocuments. Questions? Call Member Services (M-F, 8 am-6 pm) or visit kp.org Portland area: [PHONE REDACTED] All other areas: 1-[PHONE REDACTED] TTY.711. Language Interpretation Services, all areas 1-[PHONE REDACTED] This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser Foundation Health Plan of the Northwest. For more details on benefit coverage, claims review, and adjudication procedures, please see your EOC or call Member Services. In the case of a conflict between this summary and the EOC, the EOC will prevail.