kp.org/kpic/pos

Your plan for care and wellness

Member Handbook

The Kaiser Permanente Point-of-Service (POS) Plan

Please recycle. 411974561 November 2019

kp.org/kpic/pos

Your guide to good healthKeep this book handy as a quick reference to getting the most out of your plan

For information about your POS Plan benefits,call our Customer Service Line:1-800-788-0710TTY 711 Monday through Friday, 7 a.m. to 7 p.m.

Kaiser Permanente Insurance Company393 E. Walnut Street, Pasadena, CA 91188

Navajo: Saad bee áká’a’ayeed náhólǫ́ t’áá jiik’é, naadiin doo bibąą’ dį́į́’ ahéé’iikeed tsosts’id yiską́ąjį́ damoo ná'ádleehjį́. Atah halne’é áká’adoolwołígíí jókí, t’áadoo le’é t’áá hóhazaadjį́ hadilyąą’go, éí doodaii’ nááná lá ał’ąą ádaat’ehígíí bee hádadilyaa’go. Kojį́ hodiilnih 1-800-464-4000, naadiin doo bibąą’ dį́į́’ ahéé’iikeed tsosts’id yiską́ąjį́ damoo ná’ádleehjį́ (Dahodiyin biniiyé e’e’aahgo éí da’deelkaal). TTY chodeeyoolínígíí kojį́ hodiilnih 711.

Punjabi: , 24 , 7 ,

, ,

1-800-464-4000 , 24 , 7 TTY

711 ‘

Russian: Мы бесплатно обеспечиваем Вас услугами перевода 24 часа в сутки, 7 дней в неделю. Вы можете воспользоваться помощью устного переводчика, запросить перевод материалов на свой язык или запросить их в одном из альтернативных форматов. Просто позвоните нам по телефону 1-800-464-4000, который доступен 24 часа в сутки, 7 дней в неделю (кроме праздничных дней). Пользователи линии TTY могут звонить по номеру 711.

Spanish: Contamos con asistencia de idiomas sin costo alguno para usted 24 horas al día, 7 días a la semana. Puede solicitar los servicios de un intérprete, que los materiales se traduzcan a su idioma o en formatos alternativos. Solo llame al 1-800-788-0616, 24 horas al día, 7 días a la semana (cerrado los días festivos). Los usuarios de TTY, deben llamar al 711.

Tagalog: May magagamit na tulong sa wika nang wala kang babayaran, 24 na oras bawat araw, 7 araw bawat linggo. Maaari kang humingi ng mga serbisyo ng tagasalin sa wika, mga babasahin na isinalin sa iyong wika o sa mga alternatibong format. Tawagan lamang kami sa 1-800-464-4000, 24 na oras bawat araw, 7 araw bawat linggo (sarado sa mga pista opisyal). Ang mga gumagamit ng TTY ay maaaring tumawag sa 711.

Thai: เรามบีรกิารลา่มฟรสีําหรับคณุตลอด 24 ชั�วโมง ทกุวนัตลอดชั�วโมงทําการของเราคณุสามารถขอใหล้า่มชว่ยตอบคําถามของคณุที�เกี�ยวกบัความคุม้ครองการดแูลสขุภาพของเราและคณุยังสามารถขอใหม้กีารแปลเอกสารเป็นภาษาที�คณุใชไ้ดโ้ดยไมม่กีารคดิคา่บรกิารเพยีงโทรหาเราที�หมายเลข 1-800-464-4000 ตลอด 24 ชั�วโมงทกุวนั (ปิดใหบ้รกิารในวันหยดุราชการ) ผูใ้ช ้TTY โปรดโทรไปที� 711

Vietnamese: Dịch vụ thông dịch được cung cấp miễn phí cho quý vị 24 giờ mỗi ngày, 7 ngày trong tuần. Quý vị có thể yêu cầu dịch vụ thông dịch, tài liệu phiên dịch ra ngôn ngữ của quý vị hoặc tài liệu bằng nhiều hình thức khác. Quý vị chỉ cần gọi cho chúng tôi tại số 1-800-464-4000, 24 giờ mỗi ngày, 7 ngày trong tuần (trừ các ngày lễ). Người dùng TTY xin gọi 711.

INSIDE FRONT COVER

Dear member,

One of the major advantages of your POS Plan is flexibility. You can choose personalized care from Kaiser Permanente providers, participating providers in the PHCS Network for the Kaiser Permanente Insurance Company (KPIC), or non-participating providers in your community. Or you can stay with the doctor you already know and trust. We’ll be right there with you to help you make smart, well-informed decisions along the way.

With more than 160 Kaiser Permanente facilities located throughout California, you’ll probably find at least one convenient location near your work or home. Most of our facilities offer multiple services under one roof, so you can take care of several health care needs in one trip. And if you need to see a doctor right away, many of our medical facilities offer evening, weekend, and holiday hours.

We hope you’ll find this kit to be helpful and informative. Thank you for choosing Kaiser Permanente as your partner in health, and we look forward to taking care of you in many years to come.

Wishing you good health, Kaiser Permanente

Note: This is a summary only. The Kaiser Permanente POS Plan for large groups Evidence of Coverage and the Kaiser Permanente Insurance Company Certificate of Insurance contain a complete explanation of benefits, exclusions, and limitations. The information provided in this brochure is not intended for use as a benefits summary, nor is it designed to serve as the Certificate of Insurance.

3

The Kaiser Permanente Point-of-Service (POS) PlanWelcome! In this kit, you’ll find details about your POS Plan benefits, instructions on how to select a doctor and fill your prescriptions, a quick reference guide for getting care, and sample forms for filing claims.

How the POS Plan works ............................4

Your ID cards ......................................................7

Choosing your doctor...................................8

Manage your health online ..................................................................10

Getting admitted to the hospital ............................................... 11

Types of care ....................................................12

Getting your prescriptions filled .....................................13

Submitting claims .........................................14

Coordination of benefits .........................15

Helpful forms ...................................................16

Helpful terms to know ...............................18

For questions about your plan benefits, please call the Customer Service Line at 1-800-788-0710 (TTY, call 711), weekdays from 7 a.m. to 7 p.m. For faster service, please have your medical record number available when calling our Customer Service Line.

Navajo: Saad bee áká’a’ayeed náhólǫ́ t’áá jiik’é, naadiin doo bibąą’ dį́į́’ ahéé’iikeed tsosts’id yiską́ąjį́ damoo ná'ádleehjį́. Atah halne’é áká’adoolwołígíí jókí, t’áadoo le’é t’áá hóhazaadjį́ hadilyąą’go, éí doodaii’ nááná lá ał’ąą ádaat’ehígíí bee hádadilyaa’go. Kojį́ hodiilnih 1-800-464-4000, naadiin doo bibąą’ dį́į́’ ahéé’iikeed tsosts’id yiską́ąjį́ damoo ná’ádleehjį́ (Dahodiyin biniiyé e’e’aahgo éí da’deelkaal). TTY chodeeyoolínígíí kojį́ hodiilnih 711.

Punjabi: , 24 , 7 ,

, ,

1-800-464-4000 , 24 , 7 TTY

711 ‘

Russian: Мы бесплатно обеспечиваем Вас услугами перевода 24 часа в сутки, 7 дней в неделю. Вы можете воспользоваться помощью устного переводчика, запросить перевод материалов на свой язык или запросить их в одном из альтернативных форматов. Просто позвоните нам по телефону 1-800-464-4000, который доступен 24 часа в сутки, 7 дней в неделю (кроме праздничных дней). Пользователи линии TTY могут звонить по номеру 711.

Spanish: Contamos con asistencia de idiomas sin costo alguno para usted 24 horas al día, 7 días a la semana. Puede solicitar los servicios de un intérprete, que los materiales se traduzcan a su idioma o en formatos alternativos. Solo llame al 1-800-788-0616, 24 horas al día, 7 días a la semana (cerrado los días festivos). Los usuarios de TTY, deben llamar al 711.

Tagalog: May magagamit na tulong sa wika nang wala kang babayaran, 24 na oras bawat araw, 7 araw bawat linggo. Maaari kang humingi ng mga serbisyo ng tagasalin sa wika, mga babasahin na isinalin sa iyong wika o sa mga alternatibong format. Tawagan lamang kami sa 1-800-464-4000, 24 na oras bawat araw, 7 araw bawat linggo (sarado sa mga pista opisyal). Ang mga gumagamit ng TTY ay maaaring tumawag sa 711.

Thai: เรามบีรกิารลา่มฟรสีําหรับคณุตลอด 24 ชั�วโมง ทกุวนัตลอดชั�วโมงทําการของเราคณุสามารถขอใหล้า่มชว่ยตอบคําถามของคณุที�เกี�ยวกบัความคุม้ครองการดแูลสขุภาพของเราและคณุยังสามารถขอใหม้กีารแปลเอกสารเป็นภาษาที�คณุใชไ้ดโ้ดยไมม่กีารคดิคา่บรกิารเพยีงโทรหาเราที�หมายเลข 1-800-464-4000 ตลอด 24 ชั�วโมงทกุวนั (ปิดใหบ้รกิารในวันหยดุราชการ) ผูใ้ช ้TTY โปรดโทรไปที� 711

Vietnamese: Dịch vụ thông dịch được cung cấp miễn phí cho quý vị 24 giờ mỗi ngày, 7 ngày trong tuần. Quý vị có thể yêu cầu dịch vụ thông dịch, tài liệu phiên dịch ra ngôn ngữ của quý vị hoặc tài liệu bằng nhiều hình thức khác. Quý vị chỉ cần gọi cho chúng tôi tại số 1-800-464-4000, 24 giờ mỗi ngày, 7 ngày trong tuần (trừ các ngày lễ). Người dùng TTY xin gọi 711.

25 KPIC-TLC_16-004_CA

Language Assistance Services

English: Language assistance is available at no cost to you, 24 hours a day, 7 days a week. You can request interpreter services, materials translated into your language, or in alternative formats. Just call us at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). TTY users call 711.

:Arabic مجانًا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفوریةأیام األسبوع. بإمكانك طلب خدمة الترجمة الفوریة أو ترجمة وثائق للغتك أو

4000-464-800-1 لصیغ أخرى. ما علیك سوى االتصال بنا على الرقملمستخدمي خدمة على مدار الساعة كافة أیام األسبوع (مغلق أیام العطالت).

).711الرقم ( الھاتف النصي یرجي االتصال على

Armenian: Ձեզ կարող է անվճար օգնություն տրամադրվել լեզվի հարցում` օրը 24 ժամ, շաբաթը 7 օր: Դուք կարող եք պահանջել բանավոր թարգմանչի ծառայություններ, Ձեր լեզվով թարգմանված կամ այլընտրանքային ձևաչափով պատրաստված նյութեր: Պարզապես զանգահարեք մեզ` 1-800-464-4000 հեռախոսահամարով` օրը 24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է): TTY-ից օգտվողները պետք է զանգահարեն 711:

Chinese: 7 24

7 24 1-800-757-7585

(TTY) 711

:Farsi بدون روز ھفتھ 7ساعت شبانروز و 24در زبانی خدماتمترجم خدمات . شما می توانید برای استھزینھ در اختیار شما اخذ

صورتھای دیگر بھ زبان شما و یا بھ جزوات ، ترجمھشفاھی روز ھفتھ 7ساعت شبانروز و 24. کافیست در درخواست کنید

4000-464-800-1(بھ استثنای روزھای تعطیل) با ما بھ شماره .تماس بگیرند 711با شماره TTYتماس بگیرید. کاربران

Hindi: 24

1-800-464-4000 24

TTY 711

Hmong: Muajkwc pab txhais lus pub dawb rau koj, 24 teev ib hnub twg, 7 hnub ib lim tiam twg. Koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los yog ua lwm hom.Tsuas hu rau 1-800-464-4000, 24 teev ib hnub twg, 7 hnub ib lim tiam twg (cov hnub caiv kaw). Cov neeg siv TTY hu 711.

Japanese:

1-800-464-4000 TTY

711

Khmer: ជំនួយ�� គឺ�នឥតអស់ៃថ�ដល់អ�កេឡើយ 24

េ���ងមួយៃថ� 7 ៃថ�មួយ�ទិត�។ អ�ក�ចេស�ើសំុេស អ�កបកែប

សំ�រៈែដលនបកែបេ��ែខរ ឬទំរង់ផ�ឹងេទៀត។

ន់ែតទូរសព័មកេយើង មេលខ 1-800-464-4000 ន 24

េ���ងមួយៃថ� 7 ៃថ�មួយ�ទិត� (បិទៃថ�បុណ�)។ អ�កេបើ TTY

េេលខ 711។

Korean: .

, .

1-800-464-4000 ( ). TTY 711.

Laotian: ການຊວ່ຍເຫືຼອດາ້ນພາສາມໃີຫໂ້ດຍບ່ໍເສັຽຄາ່

ແກທ່າ່ນ, ຕະຫຼອດ 24 ຊ ົ່ວໂມງ, 7 ວນັຕ່ໍອາທິດ. ທາ່ນ

ສາມາດຮອ້ງຂໍຮບັບໍລິການນາຍພາສາ, ໃຫແ້ປເອກະ

ສານເປັນພາສາຂອງທາ່ນ, ຫືຼ ໃນຮບູແບບອື່ ນ. ພຽງ

ແຕໂ່ທຣຫາພວກເຮົາທ່ີ 1-800-464-4000, ຕະຫຼອດ 24

ຊ ົ່ວໂມງ, 7 ວນັຕ່ໍອາທິດ (ປິດວນັພກັຕາ່ງໆ). ຜູໃ້ຊສ້າຍ

TTY ໂທຣ 711.

4

Your POS Plan* works the way you want it to. You can choose where you get care and you can choose your own provider. Depending on scheduling availability, you have the option to:

• Visit your Kaiser Permanente doctor near your work

• Take your son to his asthma specialist, a participating provider, near your home

• Have your daughter see her non-participating specialist near her out-of-state school

Some services, such as organ transplants, vision care, and skilled nursing facility care, are covered only when you use a Kaiser Permanente provider. For a complete list of covered services, see your Evidence of Coverage (EOC) and Certificate of Insurance (COI).

Understanding your POS Plan benefits

HMO Tier Participating Provider Tier Non-Participating Provider Tier

Access

• You can visit more than 160 Kaiser Permanente facilities conveniently located throughout California. Most offer primary care, lab, X-ray, and pharmacy services together in one place.

• You choose a personal physician (practicing in internal medicine, pediatrics, or family medicine) to coordinate care and direct access to specialists.

• You can visit more than 59,000 participating provider locations in California.

• You can visit over 300 participating hospitals in California.

• You can see any other licensed provider.

• You can visit any other licensed hospital.

Costs

• Lowest copays or coinsurance.• No claims to file.

• Higher copays and coinsurance.• Providers file claims on your behalf.• There is no balance billing.

• Highest coinsurance.• You may be required to file

a claim for reimbursement.• You’re responsible for the difference

between usual, customary, and reasonable charges and actual billed charges.

• The provider may bill you for the balance of expenses.

How the POS Plan works

* The Kaiser Permanente provider tier of the Point-of-Service (POS) Plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). Kaiser Permanente Insurance Company (KPIC) underwrites the participating provider tier and the non-participating provider tier of the POS Plan. KPIC is a subsidiary of KFHP.

5

HMO TierThis option provides you quality care, convenience, and service with the most cost savings. You can choose from more than 9,100 physicians at more than 160 facilities throughout California, many of which offer evening and weekend hours.

Getting care from a Kaiser Permanente facility:• There’s no deductible before your coverage

begins.• You pay just a copay for nearly all of your

medical services, including office visits, lab tests, X-rays, and prescriptions. (Durable medical equipment requires a coinsurance payment.)

• Most preventive care is covered at no cost or a copay.

• You can refill most prescriptions online and have them mailed to your home with no-cost shipping.

To find a facility near you, visit kp.org/facilities.

Participating Provider Tier For additional flexibility, you can choose to receive your medical care through the PHCS Network for KPIC. KPIC contracts with PHCS to provide a convenient network of participating providers at competitive contracted rates.

The PHCS Network for KPIC consists of more than 60,000 doctors, specialists, and physical therapists, as well as over 300 hospitals, across the state of California. Under this option, you’ll pay a greater share of the cost, including a plan deductible and coinsurance, than if you received the same care through a Kaiser Permanente Plan provider.

Some services may require precertification. If you don’t get the required precertification, you may receive a reduction in benefits.

Non-Participating Provider TierWhen you seek care under this option, you can choose any licensed physician, hospital, lab, or other type of provider in the country. You’ll pay a greater share of the cost, including an overall deductible and coinsurance. If the provider you see doesn’t bill us directly, you’ll need to pay the costs up front and submit a claim for reimbursement.

Precertification is required for certain services. See page 9 for more information about precertification.

Out-of-pocket maximumYou have an out-of-pocket maximum. It helps limit how much you’ll pay for care. Once you meet your out-of-pocket maximum, you won’t pay anything for most covered services for the rest of the plan year. For a detailed description, see your EOC and COI. Fees, penalties, or balance billing won’t count toward your out-of-pocket maximum.

24

Language Assistance Services

English: Language assistance is available at no cost to you, 24 hours a day, 7 days a week. You can request interpreter services, materials translated into your language, or in alternative formats. Just call us at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). TTY users call 711.

:Arabic مجانًا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفوریةأیام األسبوع. بإمكانك طلب خدمة الترجمة الفوریة أو ترجمة وثائق للغتك أو

4000-464-800-1 لصیغ أخرى. ما علیك سوى االتصال بنا على الرقملمستخدمي خدمة على مدار الساعة كافة أیام األسبوع (مغلق أیام العطالت).

).711الرقم ( الھاتف النصي یرجي االتصال على

Armenian: Ձեզ կարող է անվճար օգնություն տրամադրվել լեզվի հարցում` օրը 24 ժամ, շաբաթը 7 օր: Դուք կարող եք պահանջել բանավոր թարգմանչի ծառայություններ, Ձեր լեզվով թարգմանված կամ այլընտրանքային ձևաչափով պատրաստված նյութեր: Պարզապես զանգահարեք մեզ` 1-800-464-4000 հեռախոսահամարով` օրը 24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է): TTY-ից օգտվողները պետք է զանգահարեն 711:

Chinese: 7 24

7 24 1-800-757-7585

(TTY) 711

:Farsi بدون روز ھفتھ 7ساعت شبانروز و 24در زبانی خدماتمترجم خدمات . شما می توانید برای استھزینھ در اختیار شما اخذ

صورتھای دیگر بھ زبان شما و یا بھ جزوات ، ترجمھشفاھی روز ھفتھ 7ساعت شبانروز و 24. کافیست در درخواست کنید

4000-464-800-1(بھ استثنای روزھای تعطیل) با ما بھ شماره .تماس بگیرند 711با شماره TTYتماس بگیرید. کاربران

Hindi: 24

1-800-464-4000 24

TTY 711

Hmong: Muajkwc pab txhais lus pub dawb rau koj, 24 teev ib hnub twg, 7 hnub ib lim tiam twg. Koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los yog ua lwm hom.Tsuas hu rau 1-800-464-4000, 24 teev ib hnub twg, 7 hnub ib lim tiam twg (cov hnub caiv kaw). Cov neeg siv TTY hu 711.

Japanese:

1-800-464-4000 TTY

711

Khmer: ជំនួយ�� គឺ�នឥតអស់ៃថ�ដល់អ�កេឡើយ 24

េ���ងមួយៃថ� 7 ៃថ�មួយ�ទិត�។ អ�ក�ចេស�ើសំុេស អ�កបកែប

សំ�រៈែដលនបកែបេ��ែខរ ឬទំរង់ផ�ឹងេទៀត។

ន់ែតទូរសព័មកេយើង មេលខ 1-800-464-4000 ន 24

េ���ងមួយៃថ� 7 ៃថ�មួយ�ទិត� (បិទៃថ�បុណ�)។ អ�កេបើ TTY

េេលខ 711។

Korean: .

, .

1-800-464-4000 ( ). TTY 711.

Laotian: ການຊວ່ຍເຫືຼອດາ້ນພາສາມໃີຫໂ້ດຍບ່ໍເສັຽຄາ່

ແກທ່າ່ນ, ຕະຫຼອດ 24 ຊ ົ່ວໂມງ, 7 ວນັຕ່ໍອາທິດ. ທາ່ນ

ສາມາດຮອ້ງຂໍຮບັບໍລິການນາຍພາສາ, ໃຫແ້ປເອກະ

ສານເປັນພາສາຂອງທາ່ນ, ຫືຼ ໃນຮບູແບບອື່ ນ. ພຽງ

ແຕໂ່ທຣຫາພວກເຮົາທ່ີ 1-800-464-4000, ຕະຫຼອດ 24

ຊ ົ່ວໂມງ, 7 ວນັຕ່ໍອາທິດ (ປິດວນັພກັຕາ່ງໆ). ຜູໃ້ຊສ້າຍ

TTY ໂທຣ 711.

無歧視公告

Kaiser Permanente禁止以年齡、人種、族裔、膚色、原國籍、文化背景、血統、宗教、性別、性別認同、性別表達、性取向、婚姻狀況、生理或心理殘障、付款來源、遺傳資訊、公

民身份、主要語言或移民身份為由而歧視任何人。 會員服務聯絡中心每週七天24小時提供語言協助服務（節假日除外）。本機構在全部營業時間內免費為您提供口譯，包括手語服務。我們還可為您和您的親友提供使用本機構設施與服

務所需要的任何特別協助。此外，您還可索取翻譯成您的語言的健康保險計劃資料，以及採

用大號字體或其他格式的版本來滿足您的需求。若需更多資訊，請致電1-800-757-7585（TTY專線使用者請撥711）。 投訴指任何您或您的授權代表透過流程來表達不滿的做法。例如，如果您認為自己受到歧

視，即可提出投訴。若需瞭解適用於自己的爭議解決選項，請參閱《承保範圍說明書》

（Evidence of Coverage）或《保險證明書》（Certificate of Insurance），或咨詢會員服務代表。如果您是 Medicare、Medi-Cal、MRMIP（Major Risk Medical Insurance Program, 高風險醫療保險計劃）、Medi-Cal Access、FEHBP（Federal Employees Health Benefits Program, 聯邦僱員健康保險計劃）或CalPERS會員，向會員服務代表咨詢尤其重要，因為您可能會有不同的爭議解決方式選擇。 您可透過以下途徑投訴：

• 在健康保險計劃服務設施的會員服務處填寫《投訴或福利索賠/申請表》，地址見《健康

服務指南》(Your Guidebook)。

• 將書面投訴信郵寄到健康保險計劃計劃服務設施的會員服務處（地址見《健康服務指

南》(Your Guidebook)。

• 給我們的會員服務聯絡中心打免費電話，電話號碼是1-800-757-7585（TTY專線使用者請撥711）。

• 在我們的網站上填寫投訴表，網址是kp.org 如果您在投訴時需要協助，請致電我們的會員服務聯絡中心。 涉及人種、膚色、原國籍、性別、年齡或殘障歧視的一切申訴都將通知 Kaiser Permanente的民權事務協調員（Civil Rights Coordinator）。您也可與Kaiser Permanente的民權事務協調員直接聯絡，地址：One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612。 您還可以電子方式透過民權辦公室的投訴入口網站向美國健康與公共服務部民權辦公室

（U.S. Department of Health and Human Services, Office for Civil Rights）提出民權投訴，網址是 ocrportal.hhs.gov/ocr/portal/lobby.jsf或者按照如下資訊採用郵寄或電話方式聯絡：U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697（TDD專線）。投訴表可從網站 hhs.gov/ocr/office/file/index.html下載。

23

Aviso de no discriminación Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio. La Central de Llamadas de Servicio a los Miembros brinda servicios de asistencia con el idioma las 24 horas del día, los siete días de la semana (excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de señas. También podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios. Además, puede solicitar los materiales del plan de salud traducidos a su idioma, y también los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades. Para obtener más información, llame al 1-800-788-0616 (los usuarios de la línea TTY deben llamar al 711). Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Por ejemplo, si usted cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros para conocer las opciones de resolución de disputas que le corresponden. Esto tiene especial importancia si es miembro de Medicare, Medi-Cal, el Programa de Seguro Médico para Riesgos Mayores (Major Risk Medical Insurance Program MRMIP), Medi-Cal Access, el Programa de Beneficios Médicos para los Empleados Federales (Federal Employees Health Benefits Program, FEHBP) o CalPERS, ya que dispone de otras opciones para resolver disputas. Puede presentar una queja de las siguientes maneras:

• completando un formulario de queja o de reclamación/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan (consulte las direcciones en Su Guía)

• enviando por correo su queja por escrito a una oficina de Servicio a los Miembros en un centro del plan (consulte las direcciones en Su Guía)

• llamando a la línea telefónica gratuita de la Central de Llamadas de Servicio a los Miembros al 1-800-788-0616 (los usuarios de la línea TTY deben llamar al 711)

• completando el formulario de queja en nuestro sitio web en kp.org

Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja. Se le informará al coordinador de derechos civiles de Kaiser Permanente (Civil Rights Coordinator) de todas las quejas relacionadas con la discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612. También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U.S. Department of Health and Human Services) mediante el portal de quejas formales de la Oficina de Derechos Civiles (Office for Civil Rights Complaint Portal), en ocrportal.hhs.gov/ocr/portal/lobby.jfs (en inglés) o por correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (línea TDD). Los formularios de queja formal están disponibles en hhs.gov/ocr/office/file/index.html (en inglés).

Nondiscrimination Notice Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status. Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs. For more information, call 1-800-464-4000 (TTY users call 711). A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance or speak with a Member Services representative for the dispute-resolution options that apply to you. This is especially important if you are a Medicare, Medi-Cal, MRMIP, Medi-Cal Access, FEHBP, or CalPERS member because you have different dispute-resolution options available. You may submit a grievance in the following ways: • By completing a Complaint or Benefit Claim/Request form at a Member Services office located at a

Plan Facility (please refer to Your Guidebook for addresses) • By mailing your written grievance to a Member Services office at a Plan Facility (please refer to

Your Guidebook for addresses) • By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711) • By completing the grievance form on our website at kp.org Please call our Member Service Contact Center if you need help submitting a grievance. The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612. 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 ocrportal.hhs.gov/ocr/portal/lobby.jsf 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, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at hhs.gov/ocr/office/file/index.html.

6

An example of how the provider you choose may affect your out-of-pocket costs

HMO Tier Participating Provider Tier Non-Participating Provider Tier

Deductible None $500 $1,000

Physician’s office visit

$15 copay 20% coinsurance 40% coinsurance

X-ray services No charge 20% coinsurance (after deductible is met)

40% coinsurance (after deductible is met)

Prescription drugs (prescribed by any licensed provider)

Filled at Kaiser Permanente pharmacies: $10 copay for preferred generic drugs; $30 copay for preferred brand drugsFilled at MedImpact pharmacies: $20 copay for preferred generic drugs; $40 copay for preferred brand drugs; $50 copay for non-preferred drugs

Emergency care $100 copay $100 copay $100 copay

Hospital care $200 copay per admission $250 copay + 20% coinsurance (after deductible is met)

$500 copay + 40% coinsurance (after deductible is met)

This example does not represent actual Kaiser Permanente plan figures, benefits, or deductibles. Individual situations will vary depending on the specifics of the health plan.

7

You’ll receive two POS Plan ID cards 7 to 10 business days after your coverage begins, so keep them handy.

Use your blue ID card, with the Kaiser Permanente name and logo, when you visit a Kaiser Permanente facility or pharmacy. To find a Kaiser Permanente facility or pharmacy near you, visit us online at kp.org.

Your gold and white ID card, with the PHCS and MedImpact logos, gives you access to participating providers or any other licensed provider. You can use it to fill your prescriptions through MedImpact pharmacies.

You’re also covered for emergency care 24 hours a day, 7 days a week, anywhere in the world. Always use your blue ID card when you receive emergency care.

If you haven’t received your ID cards, or you need replacements, please call us at 1-800-788-0710 or 711 (TTY), Monday through Friday from 7 a.m. to 7 p.m.

Your ID cards

Name of Insured: Medical Record Number: Rx Processor Control # (PCN): 70000 Rx Bin #003585

Point-of-Service Plan

Your Pharmacy NetworkYour Provider Network

Point-of-Service Plan

Date of Birth

Name: First M Last

Medical Record No.Prefix

kp.org

For information about your health plan benefits, call: 1-800-788-0710 or 711 (TTY)

Gender

22

Nondiscrimination Notice Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status. Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs. For more information, call 1-800-464-4000 (TTY users call 711). A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance or speak with a Member Services representative for the dispute-resolution options that apply to you. This is especially important if you are a Medicare, Medi-Cal, MRMIP, Medi-Cal Access, FEHBP, or CalPERS member because you have different dispute-resolution options available. You may submit a grievance in the following ways: • By completing a Complaint or Benefit Claim/Request form at a Member Services office located at a

Plan Facility (please refer to Your Guidebook for addresses) • By mailing your written grievance to a Member Services office at a Plan Facility (please refer to

Your Guidebook for addresses) • By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711) • By completing the grievance form on our website at kp.org Please call our Member Service Contact Center if you need help submitting a grievance. The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612. 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 ocrportal.hhs.gov/ocr/portal/lobby.jsf 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, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at hhs.gov/ocr/office/file/index.html.

21

KPIC-TL16-002-CA

ID 1-800-464-4000

1-800-927-4357 TTY 711 Japanese

می توانید از خدمات مترجم شفاھی بھره مند شوید و ترتیب خواندن متن ھا برای شما بھ زبان خودتان را بدھید. برای دریافت کمک و خدمات زبان بھ صورت رایگان.تماس بگیرید. برای دریافت کمک و راھنمایی بیشتر با اداره بیمھ کالیفرنیا بھ 4000-464-800-1 راھنمایی، با ما بھ شماره ای کھ روی کارت شناسایی شما قید شده یا

Persian تماس حاصل نمایند. 711 با شماره TTY تماس بگیرید. کاربران 4357-927-800-1 شماره

ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾ।ਂ ਤੁਸੀ ਂਇੱਕ ਦਭੁਾਸ਼ੀਏ ਦੀ ਸੇਵਾ ਹਾਸਲ ਕਰ ਸਕਦੇ ਹੋ ਅਤੇ ਤੁਹਾਨੰੂ ਦਸਤਾਵੇਜ਼ ਤੁਹਾਡੀ ਭਾਸ਼ਾ ਿਵੱਚ ਪੜ� ਕੇ ਸੁਣਾਏ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ, ਤੁਹਾਡੇ ਆਈਡੀ ਕਾਰਡ 'ਤੇ ਿਦੱਤੇ ਨੰਬਰ 'ਤੇ ਜਾਂ 1-800-464-4000 'ਤੇ ਸਾਨੰੂ ਫ਼ੋਨ ਕਰ।ੋ ਵਧੇਰੇ ਮਦਦ ਲਈ, ਕੈਲੀਫ਼ੋਰਨੀਆਂ ਿਡਪਾਰਟਮਟ ਆਫ਼ ਇਨਸ਼ੋਰਸ ਨੰੂ 1-800-927-4357 'ਤੇ ਫ਼ੋਨ ਕਰ।ੋ TTY ਦੇ ਉਪਯੋਗਕਰਤਾ 711 'ਤੇ ਫ਼ੋਨ ਕਰ।ੋ Punjabi

េស���ឥតគិតៃថ�។ អ�ក�ចទទួលអ�កបកែ�ប�ន និងឲ�េគ�នឯក�រជូនអ�ក ���ែខ�រ។ សំប់ជំនួយ សូមទូរស័ព មកេយងមេលខែដលនេេលប័ណ ID របសអ់�ក ឬ 1-800-464-4000។ សំប់ជំនួយែថមេទត ទូរស័ព េ�កសួង ប់រងរដលីហ រន៉ី មេលខ 1-800-927-4357។ អ�កេ�ប TTY េេលខ 711។ Khmer

على أو عضویتك بطاقة على المبین الرقم على بنا اتصل المساعدة، على للحصول العربیة. باللغة لك الوثائق وقراءة مترجم على الحصول یمكنك تكلفة. بدون ترجمة خدمات یرجى النصي الھاتف خدمة لمستخدمي .4357-927-800-1 الرقم على كالیفورنیا لوالیة التأمین بإدارة اتصل المعلومات من مزید على للحصول .4000-464-800-1 الرقم

Arabic.711 على االتصال

Cov Kev Pab Txhais Lus Tsis Raug Nqi Dab Tsi Koj muaj tau ib tug neeg txhais lus thiabhais tau kom nyeem cov ntaub ntawv ua koj hom lus rau koj. Xav tau kev pab, hu rau peb ntawm tus xov toojteev muaj nyob rau ntawm koj daim yuaj ID los yog 1-800-464-4000.

Xav tau kev pab ntxiv hu rau CA Tuam Tsev Tswj Kev Pov Hwm ntawm 1-800-927-4357. Cov neeg siv TTY hu rau 711. Hmong

मु�त भाषा सेवाए।ँ आप एक दभुािषया �ा� कर सकते ह� और आपको दतावेज़ आपक� भाषा म� पढ़ कर सनुाए जा सकते ह�। सहायता के िलए, अपने आईडी काड  पर िदये नबर या 1-800-464-4000 पर हम� फोन कर�। अिधक सहायता के िलए कैलीफ़ोिन या िडपाट म�ट ऑफ इशंोर�स को 1-800-927-4357 पर फोन कर�। TTY �योा 711 पर फोन कर�। Hindi

บรกิารดา้นภาษาที�ไมค่ดิคา่บรกิาร คณุสามารถขอรับบรกิารลา่มแปลภาษาและขอใหอ้า่นเอกสารใหค้ณุฟังเป็นภาษาของคณุได ้หากตอ้งการความชว่ยเหลอื โปรดโทรตดิตอ่หาเราตามหมายเลขทีระบอุยูบ่นบตัร ID ของคณุหรอืหมายเลข 1-800-464-4000 หากตอ้งการความชว่ยเหลอืในเรืองอืนๆ เพิมเตมิ โปรดโทรตดิตอ่ฝ่ายประกนัโรคมะเร็งทีหมายเลข 1-800-927-4357 ผูใ้ช ้TTY โปรดโทรไปทีหมายเลข 711. Thai

8

Seeing a doctor in the HMO Tier You’ll need to choose a Kaiser Permanente primary care physician from one of our primary care departments — internal medicine, family medicine, or pediatrics. Your primary care physician plays an important role in coordinating your care needs, including hospital stays and referrals to specialists.

Some services, such as substance use disorder treatment, family planning, obstetrics-gynecology, optometry, and psychiatry, don’t require you to get a referral. If you need a specialist like an orthopedist or a dermatologist, your primary care physician can give you a referral.

To select a primary care physician — or to change your primary care physician for any reason — please visit kp.org or call our Customer Service Line at 1-800-788-0710 or 711 (TTY), Monday through Friday from 7 a.m. to 7 p.m.

Seeing a doctor in the Participating Provider TierIf you’re seeking care from a participating provider, you can call the provider’s office to schedule an appointment. You don’t have to choose a primary care physician, and you don’t need a referral to see a specialist.

Before making an appointment, see if your doctor is in the PHCS Network for KPIC and is accepting new patients.

When you go to your appointment, please make sure that you bring your gold and white ID card with the PHCS and MedImpact logos.

To find a participating provider, please visit multiplan.com/kaiser or call 1-888-298-7427 or 711 (TTY), Monday through Friday, from 5 a.m. to 5 p.m.

Your participating provider’s office will take care of claim submissions for you.*

Seeing a doctor in the Non-Participating Provider Tier If you want to see any other licensed provider, simply call the provider’s office and make an appointment. You’ll need to remember to bring your gold and white ID card to the facility.

At your appointment, your provider may submit the claim for your visit on your behalf. Or you may be asked to pay the total costs for your medical services up front and then submit a claim for reimbursement. In either case, it will be up to you to make sure that claims are submitted for payment.

Charges for services from non-participating providers or facilities are based on the usual, customary, and reasonable charges for your geographic region, per a standardized fee schedule. Some providers may charge more than these amounts. If this happens, you’ll need to pay the difference between the usual, customary, and reasonable charges and the actual billed charges. This is called balance billing, and it doesn’t contribute toward your deductible or out-of-pocket maximum.

Choosing your doctor

* The participating provider can only collect against copays and deductibles at the time of the visit. Once the claim has been processed, any additional member liability will be listed on your Explanation of Benefits.

9

PrecertificationYou may need approval before you get certain services from a participating or non-participating provider. This is called precertification. It is an important step to make sure medical services ordered by your doctor are medically necessary, cost-effective, and the most appropriate treatment for your condition. Some examples of services requiring precertification include:• Hospital admissions• Outpatient surgeries• Inpatient rehabilitation, hospice,

or skilled nursing facility services• MRI, CT, and PET scans

To request precertification, you or your physician should call 1-888-251-7052, Monday through Friday from 6 a.m. to 6 p.m. You or your doctor should call to ask for precertification before you schedule these services. If you don’t get precertification, your benefit may be reduced by up to $500.

For a complete list of care that requires precertification, see your Certificate of Insurance.

Note: Precertification is not required for care from a Kaiser Permanente Plan provider.

Transition of careIf you’re currently receiving care, you may want to talk with one of our transition of care representatives. Our transition of care team will help ensure a seamless transition to your new coverage. They can determine if services you’re seeking require precertification, or help you find a network provider to lower your out-of-pocket costs. For information, go to kp.org/kpic/pos and look for the Member Care Transition Form located in the Documents and Forms section or call Permanente Advantage at 1-888-251-7052.

20 KPIC-TL16-002-CA

Kaiser Permanente Insurance Company

Notice of Language Assistance

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-800-464-4000. For more help call the CA Dept. of Insurance at 1-800-927-4357. TTY users call 711. English

Servicios en otros idiomas sin ningún costo. Puede conseguir un intérprete. Puede conseguir que le lean los documentos y que algunos se le envíen en su idioma. Para obtener ayuda, llámenos al número que aparece en su tarjeta de identificación o al 1-800-464-4000. Para obtener más ayuda, llame al Departamento de Seguro de CA al 1-800-927-4357. Los usuarios de la línea TTY deben llamar al 711. Spanish

免費語言服務。您可使用口譯員。您可請人將文件唸給您聽，且您可請我們將您語言版本的部分文件寄給您。如需協助，

請致電列於會員卡上的電話號碼或致電 1-800-464-4000與我們聯絡。如需進一步協助，請致電 1-800-927-4357與加州保險局聯絡。聽障及語障電話專線使用者請致電 711。Chinese

* * * * * * * * * *

No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the number listed on your ID card or 1-800-464-4000. For more help call the CA Dept. of Insurance at 1-800-927-4357. TTY users call 711. English

1-800-464-4000. CA Dept. of Insurance 1-800-927-4357. TTY 711. Navajo

Dịch vụ về ngôn ngữ miễn phí. Quý vị có thể được cấp thông dịch viên và được người đọc giấy tờ, tài liệu bằng ngôn ngữ quý vị dùng cho quý vị nghe. Để được giúp đỡ, xin gọi chúng tôi theo số điệnthoại ghi trên thẻ ID hội viên hoặc số 1-800-464-4000. Để được giúp đỡ thêm, vui lòng gọi Bộ Bảo hiểm CA theo số 1-800-927-4357. Người sử dụng TTY gọi số 711. Vietnamese

무료 언어 서비스. 한국어 통역 서비스 및 한국어로 서류를 낭독해 드리는 서비스를 제공하고 있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와 있는 전화번호 또는 1-800-464-4000번으로 문의하십시오. 보다 자세한 사항은 캘리포니아 주 보험국, 전화번호 1-800-927-4357번으로 문의하십시오. TTY 사용자 번호 711. Korean

Mga Libreng Serbisyo kaugnay sa Wika. Maaari kayong kumuha ng tagasalin-wika at hingin na basahin sa inyo ang mga dokumento sa sarili ninyong wika. Para humingi ng tulong, tawagan kami sa numerong nakasulat sa inyong ID card o sa 1-800-464-4000. Para sa karagdagang tulong tawagan ang CA Dept. of Insurance sa 1-800-927-4357. Dapat tumawag ang mga gumagamit ng TTY sa 711. Tagalog

Անվճար լեզվական ծառայություններ: Դուք կարող եք օգտվել բանավոր թարգմանչի ծառայություններից և խնդրել, որ փաստաթղթերը Ձեր լեզվով կարդան Ձեզ համար:Օգնության համար զանգահարեք մեզ` Ձեր ID քարտի վրա նշված կամ 1-800-464-4000 հեռախոսահամարով: Լրացուցիչ օգնության համար զանգահարեք Կալիֆոռնիայիապահովագրության դեպարտամենտ` 1-800-927-4357 հեռախոսահամարով: TTY -ից օգտվողները պետք է զանգահարեն 711: Armenian

Бесплатные услуги языкового перевода. Вы можете воспользоваться услугами переводчика, при этом документы могут быть зачитаны Вам на Вашем языке. Чтобы получить помощь, позвоните нам по телефону, указанному в Вашей идентификационной карточке участника, или 1-800-464-4000. За дополнительной помощью обращайтесь в Департамент страхования штата Калифорния (CA Dept. of Insurance) по телефону 1-800-927-4357. Пользователи TTY, звоните по номеру 711. Russian

KPIC-TL16-002-CA

ID 1-800-464-4000

1-800-927-4357 TTY 711 Japanese

می توانید از خدمات مترجم شفاھی بھره مند شوید و ترتیب خواندن متن ھا برای شما بھ زبان خودتان را بدھید. برای دریافت کمک و خدمات زبان بھ صورت رایگان.تماس بگیرید. برای دریافت کمک و راھنمایی بیشتر با اداره بیمھ کالیفرنیا بھ 4000-464-800-1 راھنمایی، با ما بھ شماره ای کھ روی کارت شناسایی شما قید شده یا

Persian تماس حاصل نمایند. 711 با شماره TTY تماس بگیرید. کاربران 4357-927-800-1 شماره

ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾ।ਂ ਤੁਸੀ ਂਇੱਕ ਦਭੁਾਸ਼ੀਏ ਦੀ ਸੇਵਾ ਹਾਸਲ ਕਰ ਸਕਦੇ ਹੋ ਅਤੇ ਤੁਹਾਨੰੂ ਦਸਤਾਵੇਜ਼ ਤੁਹਾਡੀ ਭਾਸ਼ਾ ਿਵੱਚ ਪੜ� ਕੇ ਸੁਣਾਏ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ, ਤੁਹਾਡੇ ਆਈਡੀ ਕਾਰਡ 'ਤੇ ਿਦੱਤੇ ਨੰਬਰ 'ਤੇ ਜਾਂ 1-800-464-4000 'ਤੇ ਸਾਨੰੂ ਫ਼ੋਨ ਕਰ।ੋ ਵਧੇਰੇ ਮਦਦ ਲਈ, ਕੈਲੀਫ਼ੋਰਨੀਆਂ ਿਡਪਾਰਟਮਟ ਆਫ਼ ਇਨਸ਼ੋਰਸ ਨੰੂ 1-800-927-4357 'ਤੇ ਫ਼ੋਨ ਕਰ।ੋ TTY ਦੇ ਉਪਯੋਗਕਰਤਾ 711 'ਤੇ ਫ਼ੋਨ ਕਰ।ੋ Punjabi

េស���ឥតគិតៃថ�។ អ�ក�ចទទួលអ�កបកែ�ប�ន និងឲ�េគ�នឯក�រជូនអ�ក ���ែខ�រ។ សំប់ជំនួយ សូមទូរស័ព មកេយងមេលខែដលនេេលប័ណ ID របសអ់�ក ឬ 1-800-464-4000។ សំប់ជំនួយែថមេទត ទូរស័ព េ�កសួង ប់រងរដលីហ រន៉ី មេលខ 1-800-927-4357។ អ�កេ�ប TTY េេលខ 711។ Khmer

على أو عضویتك بطاقة على المبین الرقم على بنا اتصل المساعدة، على للحصول العربیة. باللغة لك الوثائق وقراءة مترجم على الحصول یمكنك تكلفة. بدون ترجمة خدمات یرجى النصي الھاتف خدمة لمستخدمي .4357-927-800-1 الرقم على كالیفورنیا لوالیة التأمین بإدارة اتصل المعلومات من مزید على للحصول .4000-464-800-1 الرقم

Arabic.711 على االتصال

Cov Kev Pab Txhais Lus Tsis Raug Nqi Dab Tsi Koj muaj tau ib tug neeg txhais lus thiabhais tau kom nyeem cov ntaub ntawv ua koj hom lus rau koj. Xav tau kev pab, hu rau peb ntawm tus xov toojteev muaj nyob rau ntawm koj daim yuaj ID los yog 1-800-464-4000.

Xav tau kev pab ntxiv hu rau CA Tuam Tsev Tswj Kev Pov Hwm ntawm 1-800-927-4357. Cov neeg siv TTY hu rau 711. Hmong

मु�त भाषा सेवाए।ँ आप एक दभुािषया �ा� कर सकते ह� और आपको दतावेज़ आपक� भाषा म� पढ़ कर सनुाए जा सकते ह�। सहायता के िलए, अपने आईडी काड  पर िदये नबर या 1-800-464-4000 पर हम� फोन कर�। अिधक सहायता के िलए कैलीफ़ोिन या िडपाट म�ट ऑफ इशंोर�स को 1-800-927-4357 पर फोन कर�। TTY �योा 711 पर फोन कर�। Hindi

บรกิารดา้นภาษาที�ไมค่ดิคา่บรกิาร คณุสามารถขอรับบรกิารลา่มแปลภาษาและขอใหอ้า่นเอกสารใหค้ณุฟังเป็นภาษาของคณุได ้หากตอ้งการความชว่ยเหลอื โปรดโทรตดิตอ่หาเราตามหมายเลขทีระบอุยูบ่นบตัร ID ของคณุหรอืหมายเลข 1-800-464-4000 หากตอ้งการความชว่ยเหลอืในเรืองอืนๆ เพิมเตมิ โปรดโทรตดิตอ่ฝ่ายประกนัโรคมะเร็งทีหมายเลข 1-800-927-4357 ผูใ้ช ้TTY โปรดโทรไปทีหมายเลข 711. Thai

19

KPIC-ND18-010-CA (3/2018)

Nondiscrimination NoticeKaiser Permanente Insurance Company (KPIC) does not discriminate based on race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). We can provide no cost aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters and written information in other formats; large print, audio, and accessible electronic formats. We also provide no cost language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. To request these services, please call 1-800-464-4000 (TTY users call 711).

If you believe that KPIC failed to provide these services or there is a concern of discrimination based on race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability you canfile a complaint by phone or mail with the KPIC Civil Rights Coordinator. If you need help filing a grievance, the KPIC Civil Rights Coordinator is able to help you.

KPIC Civil Rights CoordinatorGrievance 1557

5855 Copley Drive, Suite 250San Diego, CA 92111

1-888-251-7052

You may also contact the California Department of Insurance regarding your complaint.

By Phone:California Department of Insurance

1-800-927-HELP(1-800-927-4357)

TDD: 1-800-482-4TDD(1-800-482-4833)

By Mail:California Department of InsuranceConsumer Communications Bureau

300 S. Spring StreetLos Angeles, CA 90013

Electronically:www.insurance.ca.gov

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rightsif there is a concern of discrimination based on race, color, national origin, age, disability, or sex. You can file the complaint electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, 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, 1-800-368-1019, 1-800-537-7697(TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

KPIC-ND18-010-CA (3/2018)

Nondiscrimination NoticeKaiser Permanente Insurance Company (KPIC) does not discriminate based on race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). We can provide no cost aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters and written information in other formats; large print, audio, and accessible electronic formats. We also provide no cost language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. To request these services, please call 1-800-464-4000 (TTY users call 711).

If you believe that KPIC failed to provide these services or there is a concern of discrimination based on race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability you canfile a complaint by phone or mail with the KPIC Civil Rights Coordinator. If you need help filing a grievance, the KPIC Civil Rights Coordinator is able to help you.

KPIC Civil Rights CoordinatorGrievance 1557

5855 Copley Drive, Suite 250San Diego, CA 92111

1-888-251-7052

You may also contact the California Department of Insurance regarding your complaint.

By Phone:California Department of Insurance

1-800-927-HELP(1-800-927-4357)

TDD: 1-800-482-4TDD(1-800-482-4833)

By Mail:California Department of InsuranceConsumer Communications Bureau

300 S. Spring StreetLos Angeles, CA 90013

Electronically:www.insurance.ca.gov

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rightsif there is a concern of discrimination based on race, color, national origin, age, disability, or sex. You can file the complaint electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, 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, 1-800-368-1019, 1-800-537-7697(TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

10

Manage your health onlineWhen you receive care at Kaiser Permanente facilities, you can manage your care on your own time at kp.org. To use these features for the first time, you’ll need to register at kp.org/register. Then just sign on with your user ID and password.

You can also access kp.org from your mobile device. Just download the Kaiser Permanente app to your smartphone or mobile device from your preferred app site.

To learn more about your POS Plan, go to kp.org/kpic/pos to access these features:• Search for doctors and facilities within the

PHCS Network for KPIC.• Get details on filing claims, our drug formulary,

the grievance/appeals process, and more.• Visit the Documents and Forms section link

to download fact sheets and forms.

Access kp.org at home or on the go

What you can do What you can see

• Email your Kaiser Permanente doctor’s office with nonurgent questions

• Request, cancel, or review routine appointments• Order most prescription refills and check the status

of prescription refills• Request a change to your medical record• Act for a family member (within the limitations

of state and federal law)• Complete a Total Health Assessment and send the

results to your doctor

• Most lab test results• Email alerts for upcoming appointments,

lab test results, and unread messages• Immunization records• Medication allergies• Past office visit information• Health care reminders• Ongoing medical condition information• Benefit and eligibility information• A summary of your medical history

11

Whether it’s an emergency admission or a scheduled hospitalization, the hospital that admits you determines your benefits and out-of-pocket costs.

HMO Tier If you’re admitted to a Kaiser Permanente hospital, you’ll just pay a copay for admission, whether it’s an emergency admission or not. Precertification is not required when you are admitted to a Kaiser Permanente hospital.

Participating Provider Tier You may also be admitted to a hospital in the PHCS Network for KPIC. Upon meeting your POS Plan deductible, you’ll pay your inpatient hospitalization copay for each admission and a percentage of the charges for services you received during your stay. Your share of the cost of any services you have received will not exceed your out-of-pocket maximum.

Note: Precertification is required.

Non-Participating Provider Tier You may also obtain hospital care from any licensed non-participating provider. Upon meeting your POS Plan deductible, you’ll pay your inpatient hospitalization copay, then coinsurance (up to the out-of-pocket maximum), plus any amounts billed by your provider that are in excess of usual, customary, and reasonable charges.

Note: Precertification is required.

TransfersIf you’re admitted to a non–Kaiser Permanente hospital, you can be transferred to a Kaiser Permanente hospital once your treating physician determines that your condition is stable and you’re well enough to be transferred. In order to take advantage of your HMO Tier hospitalization benefit, your care must be managed by a Kaiser Permanente medical team.

If you’re admitted to a Kaiser Permanente hospital, you can choose to transfer to a non–Kaiser Permanente hospital when your condition becomes stable.

You’ll need to get precertification, and your out-of-pocket expenses will be higher than those within Kaiser Permanente hospitals. Your out-of-pocket expenses will vary depending on the facility you select to provide your care.

If a Kaiser Permanente physician refers you to a non–Kaiser Permanente hospital for treatment, the specialized treatment for which your Kaiser Permanente physician referred you will be covered as an HMO Tier benefit for as long as those services are authorized by a Kaiser Permanente physician.

Getting admitted to the hospital

18

Balance billing: When a provider bills you for the difference between what they charge and what is the maximum amount allowed by your plan. For example, if a provider’s charge for a service is $120 and the amount allowed by your plan is $100, the provider may bill you for the remaining $20.

Coinsurance: A percentage of the charges you must pay when you receive health care services.

Copay: A specific dollar amount you must pay for covered health care services.

Deductible: A set amount that you or your family must meet for the cost of covered services before your copay or coinsurance applies. (For example, you may be responsible for the first $500 in charges.) Typically, most services covered at a copay, such as routine exams, preventive screenings, and outpatient drugs, are not subject to a deductible. We don’t cover certain services until you meet your deductibles each plan year.Your POS Plan benefits summary provides a brief description of covered services where deductibles apply. For a detailed description, please refer to your EOC and COI.

Maximum allowable charge: Payments under your plan for the participating and non-participating provider options are based on the maximum allowable charges for covered services. For participating providers, it is the negotiated rate contractually agreed upon to provide discounts for covered services. For non-participating providers, it is the lesser of the usual, customary, and reasonable (UCR) charges and actual billed charges. This amount may be less than the amount billed by your provider. You may be responsible for any amount in excess of the maximum allowable charge when seeking care from non-participating providers.

Usual, customary, and reasonable (UCR) charges: The general level of charges made by other providers for specified covered services within the area where the charge is incurred.

Helpful terms to know

17

Filling your prescription needs Kaiser Permanente Insurance Company (KPIC) member:

In addition to filling your covered prescriptions at Kaiser Permanente Pharmacies, as a Point-of-Service (POS) member, you also have the freedom of visiting any MedImpact Pharmacy.*

The network of MedImpact Pharmacies includes over 60,000 chain and independent pharmacies nationwide, so you can always find a location convenient to your home or office. To find a MedImpact Pharmacy near you, call 1-800-788-2949.

When visiting a MedImpact PharmacyTo help ensure your prescriptions are processed as quickly as possible, please give the pharmacist your gold-and-white identification card with the MedImpact logo, along with the message at the bottom of this page. This should clear up any questions the pharmacist may have about your coverage.

If you have any questions about your benefits, call the KPIC Customer Service line at 1-800-788-0710, Monday through Friday, 7 a.m. to 7 p.m.

*Your out-of-pocket costs may be higher at MedImpact Pharmacies. For specific cost information, please call KPIC Customer Service at 1-800-788-0710.

MedImpact pharmacist:

This insured is covered for pharmacy services at MedImpact Pharmacies through the KPIC Point of Service (POS) plan. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc. Please do not redirect this member to a Kaiser Permanente facility to fill his or her prescriptions.

Check the member’s ID card for the information you need to fill the prescription, or refer to the information below. If you have any questions or need to verify eligibility, call MedImpact at 1-800-788-2949.

We appreciate your help in providing prescription services to our members.

Member name: ____________________________________ Medical record number: ______________________

Benefit identification number (BIN): 003585Processor control number (PCN): 70000

Save time and gas money: have most prescriptions mailed to youWhen you fill any of your prescriptions at a Kaiser Permanente pharmacy, you have the added convenience of refilling most of those prescriptions online. Skip the trip to the pharmacy—we’ll mail most prescriptions to your home and ship them at no additional charge. To find out about transferring your non–Kaiser Permanente prescriptions to one of our pharmacies, talk with your Kaiser Permanente doctor. You can also visit kp.org/myhealthmanager to learn more.

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For membersGetting ready to schedule an appointment? If you’ve got a Point-of-Service (POS), PPO, or Out-of-Area Indemnity (OOA) plan with Kaiser Permanente Insurance Company (KPIC), you can get care from any licensed provider you choose.

To make your appointment go as smoothly as possible, you should:

1. Make sure the doctor you’ve chosen is accepting new patients when you schedule your appointment

2. Make a copy of this form, bring it to your appointment, and share it with the provider at check-in

3. Remember to let your provider know you have a POS, PPO, or OOA plan

If you have questions, call KPIC Member Service at 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. Pacific time.

For ProvidersThis member has a POS, PPO, or OOA plan, which lets them get care from any licensed provider they choose. Please don’t send them to Kaiser Permanente facilities to get care.

Here’s how to help them during their visit:• Check their medical ID card and call

1-800-788-0710 to make sure they’re eligible.• Submit claims to KPIC on this member’s behalf

to: KPIC, P.O. Box 261155, Plano, TX 75026.

• If they need hospitalization or a medical service or item that requires precertification, call 1-888-251-7052, Monday through Friday, 6 a.m. to 6 p.m. Pacific time. Please call 3 days before any scheduled admissions or within 24 hours of an emergency admission.

Thank you for helping this member get the care they need. Please put this form in their medical record or billing files as a reminder of the steps above.

Preparing for your appointment with a non-participating provider

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The HMO Tier of the Point-of-Service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). Kaiser Permanente Insurance Company (KPIC) underwrites the Participating and Non-Participating Provider tiers of the POS plan, the PPO plan, and Out-of-Area Indemnity plan. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc.

Don’t forget your ID cardYour gold and white ID card has important information to help you check in for your appointment, including the name of your health plan and medical record number.

Name of Insured: Medical Record Number: Rx Processor Control # (PCN): 70000 Rx Bin #003585

Health plan

Your Pharmacy NetworkYour Provider Network

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Permanente Advantage, LLC Case Management Department 5855 Copley Drive, Suite 250, San Diego, CA 92111 Phone: 888-251-7052 Fax: 866-338-0266 Email: permanente.advantage@kponcall.com

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Member Care Transition Form Our goal is to make your transition of care as easy as possible. Please complete each section so we can best serve you. Once we receive your form, we will review the information and have a transition of care representative or nurse case manager contact you within five business days. We look forward to being your partner in health Note: Permanente Advantage provides medical review and case management for Kaiser Permanente Insurance Company (KPIC) Point-of-Service (POS), PPO and Out-of-Area (OOA) plans only.

SECTION 1 Employer name: _________________________________________ Date of coverage: ____ / ____ / _______ Member’s last name: _____________________________ Member’s first name: _________________________ Date of birth: ____ / ____ / _______ Health record no.: ________________________ Gender: M F Relationship to employee: Self Spouse/Domestic Partner Child/Dependent Address: _______________________________________________________________________________________ Phone number: ____________________________ Best time to call: __________________________________

SECTION 2 Please tell us about your health care needs by answering the following questions. Yes No Are you pregnant? (Due Date: ____ / ____ /____ Trimester: ____ 1st ____ 2nd ____ 3rd) If yes, is your pregnancy considered high risk (multiple births, gestational diabetes, etc.)? Yes No Yes No Are you scheduled for surgery or hospitalization? Scheduled date: : ____ / ____ /____ Type of surgery or procedure: ________________________________________________________ Yes No Are you receiving chemotherapy, radiation therapy, cancer therapy, or dialysis treatment? Type of treatment: __________________________________________________________________ Yes No Are you receiving treatment related to a recent major surgery? Type of surgery or procedure: ________________________________________________________ Yes No Are you receiving mental health treatment or substance abuse treatment? Yes No Are you currently using durable medical equipment (hospital bed, oxygen, etc.)? Yes No Are you currently being treated with specialty pharmacy drugs (for conditions such as Multiple

Sclerosis, Organ Transplant, HIV, Hepatitis, Osteoporosis, Auto-Immune disease, etc.)? Condition being treated: _____________________________________________________________

SECTION 3 Yes No Are you currently working with a physician or dedicated case manager for your condition(s)? Physician or Case manager name:

________________________________

Phone number:

_____________________________

Specialty: _______________________________ Condition: _________________________________________

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Member Care Transition FormUse this form when you are seeking health care services from a participating or non-participating provider and want help transitioning to your new coverage.

MedImpact Pharmacy FlierGive a copy of this form to your MedImpact pharmacist. It will help identify you as a Kaiser Permanente POS Plan member with access to the MedImpact network of pharmacies. It also gives the pharmacist important information about filling prescriptions on your behalf.

Obtaining Services Out of NetworkGive a copy of this form to your non-participating provider. It will help identify you as a Kaiser Permanente POS Plan member with access to care from any licensed provider. It also gives the provider’s office information about filing claims on your behalf.

Helpful forms (continued)

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Urgent care An urgent care need is one that requires

prompt medical attention, usually within 24 or 48 hours, but is not an emergency medical condition. This can include minor injuries, backaches, earaches, sore throats, coughs, upper-respiratory symptoms, and frequent urination or a burning sensation when urinating. If you think you may need urgent care, call your local Kaiser Permanente facility, an urgent care facility or provider in the PHCS Network for KPIC, or any other licensed urgent care facility or provider. Urgent care is covered according to your plan benefits.

Emergency care You’re covered for emergency care*

anywhere in the world. If you have an emergency medical condition, call 911 or go to the nearest hospital. You’ll be responsible for an emergency department copay, which will be waived if you’re admitted to the hospital. If you’re admitted, please call us (or have someone else do so) at 1-800-225-8883 or 1-800-788-0710 as soon as possible. We’ll help coordinate your care to reduce your risk of being billed for noncovered charges.

Remember to always use your blue Kaiser Permanente ID card when receiving emergency care, regardless of where you receive care.

Post-stabilization care

Post-stabilization care refers to the services you receive after your treating physician determines that your emergency medical condition is clinically stable.

If you receive post-stabilization care from a participating or non-participating provider, you can:

• Move to a Kaiser Permanente facility by calling 1-800-225-8883 to request authorization and transfer arrangements

• Remain at the non–Kaiser Permanente facility and receive care under the participating or non-participating provider tier benefits in your plan, by calling 1-888-251-7052 for precertification and utilization management services, if needed

Please note: Your out-of-pocket costs will be greater if you elect to receive care from a non-participating provider.

Please refer to your EOC and COI for coverage information, exclusions, and limitations.

Getting care away from home POS members are able to get care in any

other Kaiser Permanente service area and also have access to providers nationwide. The coverage is the same in another Kaiser Permanente area as it is in your home area.

Types of care

* An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person would have believed that the absence of immediate medical attention would result in any of the following: (1) placing the person’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.

A mental health condition is an emergency medical condition when it meets the requirements of the paragraph above or, for members who are not enrolled in Kaiser Permanente Senior Advantage, when the condition manifests itself by acute symptoms of sufficient severity such that either of the following is true: The person is an immediate danger to himself or herself or to others, or the person is immediately unable to provide for or use food, shelter, or clothing due to the mental disorder.

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Getting your prescriptions filledKaiser Permanente pharmaciesYou can have your prescriptions, including those written by participating providers or any other licensed provider, filled at any of our Kaiser Permanente pharmacies.* Prescriptions filled at Kaiser Permanente pharmacies will be covered at the lower copay amount.

To fill a prescription at a Kaiser Permanente pharmacy, just show your blue Kaiser Permanente ID card to the pharmacist. (See page 7 for more information about your ID cards.)

Participating retail pharmaciesA generic drug will always be supplied in place of a brand-name drug, unless your doctor specifically requests the brand.

You can fill your prescriptions at any of the over 59,000 retail pharmacies nationwide in the MedImpact network. MedImpact contracts with individual retail pharmacies to offer you a wide network of pharmacies across the country. You’ll pay a higher copay at MedImpact pharmacies than you would at Kaiser Permanente pharmacies, but you’ll have many convenient locations to choose from.

MedImpact pharmacies include Walgreens, CVS, Rite Aid, Ralphs, Safeway, Costco, and many more. (MedImpact pharmacies are subject to change.) To fill a prescription at a MedImpact pharmacy, just show your gold and white ID card. Certain drugs have recommended prescribing guidelines that may apply, such as prior authorization or step therapy. For more information, call 1-800-788-2949, 24 hours a day, 7 days a week.

Prescription refillsHere are 3 convenient ways to order most of your prescription refills without standing in line when you use a Kaiser Permanente pharmacy. • Online. Visit kp.org/rxrefill to order and check

the status of your refills. To access this feature, just register at kp.org/register, then sign in with your user ID and password.

• Using our automated telephone system. Call the pharmacy refill phone number on your prescription label. Have your medical record number and credit card or debit card information handy.

• By mail. You can also order most prescription refills using our preprinted mail-order forms, which are available at any Kaiser Permanente pharmacy. Complete the form, drop it in the mail, and you should receive your prescription within 2 weeks.

Refills can be paid with a current, valid credit card: American Express, Discover, MasterCard, or Visa. You can also pay with a debit card (with the MasterCard or Visa logo).

Transferring a prescriptionYou can easily transfer your prescriptions between MedImpact pharmacies, or from a MedImpact pharmacy to a Kaiser Permanente pharmacy.* You can also transfer prescriptions from a Northern California Kaiser Permanente pharmacy to a Southern California Kaiser Permanente pharmacy (and vice versa). Just give the Kaiser Permanente pharmacist the name and phone number of your current pharmacy and the prescription number from the drug label. The pharmacist will do the rest. The prescription can be transferred as long as there are refills remaining.

* Only covered prescriptions based on plan coverage can be filled at a Kaiser Permanente pharmacy.

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For membersGetting ready to schedule an appointment? If you’ve got a Point-of-Service (POS) or PPO plan with Kaiser Permanente Insurance Company (KPIC), you can get care from participating providers in the PHCS Network for KPIC or any licensed provider you choose.

To make your appointment go as smoothly as possible, you should:

1. Visit multiplan.com/kaiser to make sure your doctor and medical facility are participating in the PHCS Network for KPIC

2. Make a copy of this form, bring it to your appointment, and share it with your provider at check-in

3. Remember to let your provider know that you have a KPIC POS or PPO plan

For providersThis member has a POS or PPO plan, which lets them get care from participating providers in the PHCS Network for KPIC or any licensed provider they choose. Please don’t send them to Kaiser Permanente facilities to get care.

Here’s how to help them during their visit:• Check their KPIC medical ID card and call

1-800-788-0710 to make sure they’re eligible.• Submit claims to KPIC on this member’s behalf

to: KPIC, P.O. Box 261155, Plano, TX 75026. • Collect any payments they’re responsible for,

including charges before reaching their deductible, copays, and noncovered expenses.

• If they need a referral for specialty care, refer them to a participating provider.

• If they need hospitalization or a medical service or item that requires precertification, call 1-888-251-7052, Monday through Friday, 6 a.m. to 6 p.m. Pacific time. Please call 3 days before any scheduled admissions or within 24 hours of an emergency admission.

Thank you for helping this member get the care they need. Please put this form in their medical record or billing files as a reminder of the steps above.

If you have any questions, call PHCS at 1-888-298-7427, Monday through Friday, 5 a.m. to 5 p.m. Pacific time.

Preparing for your appointment with a participating provider

Please recycle. 60689511 October 2017

The HMO Tier of the Point-of-Service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). Kaiser Permanente Insurance Company (KPIC) underwrites the Participating and Non-Participating Provider tiers of the POS plan and the PPO plan. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc.

Don’t forget your ID cardYour gold and white ID card has important information to help you check in for your appointment, including the name of your health plan and medical record number.

Name of Insured: Medical Record Number: Rx Processor Control # (PCN): 70000 Rx Bin #003585

Health plan

Your Pharmacy NetworkYour Provider Network

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The forms below can help you when you need to file a claim, get reimbursed for expenses you’ve incurred, or let your doctor’s office know about your benefits. To get copies of these forms, just call our KPIC Customer Service Line at 1-800-788-0710 or 711 (TTY), Monday through Friday from 7 a.m. to 7 p.m., or visit kp.org/kpic/pos and click on the “Documents and Forms” section.

Medical Claim Form Kaiser Permanente Insurance Company

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS FORM. PLEASE PRINT IN INK. Please submit one claim form per patient. All questions must be answered for prompt processing. Attach itemized bills from your hospital, doctor, or pharmacy. The bills should include the patient’s name, diagnosis, date of service, type of service, and charge. Note: All claims must be filled within one year from the date of service. SEND THIS COMPLETED CLAIM FORM TO: KAISER PERMANENTE INSURANCE COMPANY (KPIC) P.O. BOX 261155 PLANO, TX 75026 CUSTOMER SERVICE NUMBER: 1-800-392-8649

EMPLOYEE/RETIREE DATA

NAME OF EMPLOYER

GROUP ID WORK PHONE ( )

HOME PHONE ( )

EMPLOYEE NAME LAST FIRST MIDDLE

SOCIAL SECURITY NUMBER MEDICAL RECORD #

HOME ADDRESS STREET CITY STATE ZIP CODE

MARITAL STATUS __ Single __Married __Divorced __Widowed __ Separated

OTHER INSURANCE? __ Yes __ No If yes, complete section below.

PATIENT DATA

PATIENT NAME LAST FIRST MIDDLE

SEX __ Male __ Female

PHONE NUMBER

DATE OF BIRTH AGE DISABLED DEPENDENT __ Yes __ No

RELATIONSHIP TO EMPLOYEE __ Husband __Wife __ Domestic Partner __ Son __ Daughter __ Other (Describe)__________________

Were these charges incurred as a result of an on-the-job illness or injury? __ Yes __ No Other accident __ Yes __ No If the claim is the result of any kind of accident or injury, complete the following information: Date:____________________ Time:__________________ Description of what happened:_________________________________________________________________________________________________

OTHER INSURANCE DATA – PLEASE READ INSTRUCTIONS ON BACK

IS THIS PATIENT EMPLOYED? __ Yes __ No

IF YES, GIVE NAME AND ADDRESS OF EMPLOYER.

IS THIS PATIENT OR ANY OTHER FAMILY MEMBER COVERED BY OTHER GROUP HEALTH INSURANCE? __ Yes __ No If yes, complete section.

Name of Insured Name/Address of Insurance company ID Number Group Number

IS THE PATIENT COVERED BY MEDICARE? __