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MK-43A Copay B Plan: Vision January 1, 2026 - December 31, 2026 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 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: -Get Care Now with a Clinician – Talk to a clinician 24/7 over video or phone for quality care when you need it – no appointment needed. Using your Kaiser Permanente App, select Get Care Now on the home screen, and then select Get Care Now with a Clinician to start the process. You can also visit kp.org/getcare to learn more about your care options. -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. Health and Wellness Classes & Resources: kp.org/healthengagement Find information, tips, and resources you can use to help you take charge of your health. Browse the available classes online or learn more about health coaching. Wellness Resources: kp.org/health-wellness As a Kaiser Permanente member, you can enjoy no-cost and discounted online tools, apps, classes, programs, and activities that can help keep you happy and healthy. 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 Evidence of Coverage (EOC) or call Member Services. In the case of a conflict between this summary and the EOC, the EOC will prevail. EOCs are available upon request or you may go to kp.org/plandocuments.