KP Plus 2500

Source answer: In-Network Provider: $2,500 Individual / $5,000 Family Out-of-Network Provider: None

Benefit details: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Benefit details: Summary (In-Network): Individual deductible: $2,500 per calendar year Family deductible: $5,000 per calendar year

Source answer: No.

Benefit details: You don’t have to meet deductibles for specific services.

In-Network: $30 copay, deductible and coinsurance do not apply

In-Network: Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.

Source answer: In-Network Provider: $6,000 Individual / $12,000 Family Out-of-Network Provider: No Limit

Benefit details: 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 ownout-of-pocket limits until the overall family out-of-pocket limit has been met.

Benefit details: Summary (In-Network): Individual out-of-pocket limit: $6,000 Family out-of-pocket limit: $12,000 Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: All cost shares for covered services

Source answer: Premiums, balance-billing charges, health care this plan doesn’t cover, and services indicated in chart starting on page 2.

Benefit details: Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

In-network: $30 / visit, deductible does not apply.

Benefit details: Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

In-network: $30 / visit, deductible does not apply.

Benefit details: Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

In-network: No charge, deductible does not apply.

Benefit details: 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. Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

Benefit details: Summary (In-Network): Covered in full Women's contraception is covered as preventive, and Men's contraception is covered in full

In-network: 30% coinsurance

Benefit details: Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

Benefit details: Summary (In-Network): Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance apply High end radiology imaging services such as CT, MRI and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services.

In-network: 30% coinsurance

Benefit details: Preauthorization required

In-network: $25 (retail); $50 (mail order) / prescription, deductible does not apply.

Benefit details: Up to a 90-day supply (retail / mail order). No charge for contraceptives. Subject to formulary guidelines. Out-of-Network Provider: Limited to 5 prescription fills up to a 30-day supply per year.

In-network: $50 (retail); $100 (mail order) / prescription, deductible does not apply.

Benefit details: Up to a 90-day supply (retail / mail order). Subject to formulary guidelines. Out-of- Network Provider: Limited to 5 prescription fills up to a 30-day supply per year.

In-network: Applicable preferred generic or Preferred brand cost shares apply.

Benefit details: Up to a 90-day supply (retail / mail order). Subject to formulary guidelines, when approved through the exception process..

In-network: 50% coinsurance up to $150 (retail) / prescription, deductible does not apply

Benefit details: Up to a 30-day supply (retail). Subject to formulary guidelines.

In-Network: Preferred generic/preferred brand/preferred specialty $25/$50/50% up to $150 per 30 day supply

In-Network: 2x prescription cost share per 90 day supply

In-network: 30% coinsurance

In-network: 30% coinsurance

In-network: 30% coinsurance

Benefit details: Preauthorization required

In-network: 30% coinsurance

Benefit details: Preauthorization required

In-Network: Inpatient services: Deductible and coinsurance apply Outpatient surgery: Deductible and coinsurance apply

In-Network: Unlimited, no waiting period Inpatient: Deductible and coinsurance apply Outpatient: $30 copay, deductible and coinsurance do not apply

Source statement: Cosmetic Surgery is listed in the source exclusions; review the qualifications.

In-network: $200 / visit, then 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours if admitted to an Out-of-Network Provider; limited to initial emergency only. Copayment waived if admitted directly to the hospital as an inpatient. The In-Network deductible applies for Out-of-Network Providers.

Benefit details: Summary (In-Network): $200 copay Deductible and coinsurance apply

In-network: 20% coinsurance, deductible does not apply.

Benefit details: Summary (In-Network): Plan pays 80%, you pay 20%

In-network: $30 / visit, deductible does not apply.

Benefit details: The In-Network deductible applies for Out-of- Network Providers.

In-network: $30 / visit, deductible does not apply.

Benefit details: Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

In-network: 30% coinsurance

Benefit details: Preauthorization required

In-Network: Deductible and coinsurance apply

In-Network: $30 copay, deductible and coinsurance do not apply

In-Network: Deductible and coinsurance apply

In-Network: $30 copay, deductible and coinsurance do not apply

In-network: 30% coinsurance

Benefit details: Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

In-network: 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother.

In-network: 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother.

In-Network: Inpatient: Deductible and coinsurance apply Outpatient: $30 copay, deductible and coinsurance do not apply. Routine care not subject to outpatient services copay.

In-Network: Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother.

In-network: No Charge, deductible does not apply.

Benefit details: 130 visit limit / year. Preauthorization required

Benefit details: Summary (In-Network): Covered in full up to 130 visits total per calendar year

In-network: Outpatient: $30 / visit, deductible does not apply. Inpatient: 30% coinsurance

Benefit details: Combined with Habilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year. Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year. Preauthorization required

Benefit details: Summary (In-Network): Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. $30 copay, deductible and coinsurance do not apply

In-network: Outpatient: $30 / visit, deductible does not apply. Inpatient: 30% coinsurance

Benefit details: Combined with Rehabilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year. Out-of-Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year. Preauthorization required

In-network: 30% coinsurance

Benefit details: 60-day limit / year. Preauthorization required

Benefit details: Summary (In-Network): Up to 60 days per calendar year, deductible and coinsurance apply

In-network: 20% coinsurance, deductible does not apply.

Benefit details: Subject to formulary guidelines. Preauthorization required

Benefit details: Summary (In-Network): Covered at 80%

In-network: No charge, deductible does not apply.

Benefit details: Preauthorization required

Benefit details: Summary (In-Network): Covered in full

In-Network: See Rehabilitation services

Benefit details: Referenced summary Rehabilitation services: Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. $30 copay, deductible and coinsurance do not apply

In-network: $30 / visit for refractive exam, deductible does not apply.

Benefit details: Limited to 1 exam / 12 months. Out-of- Network Provider: Limited to certain benefits up to a combined maximum of 10 services per year.

In-network: Not covered

In-network: Not covered

In-Network: $30 copay, deductible and coinsurance waived

In-Network: Not covered

Source answer: Yes, but you may self-refer to certain specialists.

Benefit details: 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.

Source answer: Yes. See www.kp.org or call 1-888- 901-4636 (TTY: 711) for a list of network providers.

Benefit details: 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.

Benefit details: Non-emergency care when traveling outside the U.S. Listed under services the plan generally does not cover; see the EOC for emergency and other travel terms.

KP Plus

Benefit details: Health Plan label from the exact January 2027 summary. EOC booklets are marked tbd; confirm the detailed provider network and current participation.

In-Network: No PEC

In-Network: Unlimited

Benefit details: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs

Benefit details: Limitations may apply; this is not a complete list. See the plan document. • Acupuncture (12 visit limit / year) • Chiropractic care (12 visit limit / year) • Hearing aids (1 aid / ear / 36 months) • Routine eye care (Adult)

Deductibles: $2,500

Copayments: $10

Coinsurance: $2,700

Limits or exclusions: $20

Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ.

Deductibles: $40

Copayments: $1,400

Coinsurance: $0

Limits or exclusions: $0

Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ.

Deductibles: $900

Copayments: $200

Coinsurance: $200

Limits or exclusions: $0

Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ.

In-Network: Covered in full

In-Network: Covered up to 12 visits per calendar year $30 copay, deductible and coinsurance do not apply

In-Network: $30 copay, deductible and coinsurance do not apply

In-Network: 1 aid per ear every 36 months; Covered at 80%

In-Network: Not covered

In-Network: Covered up to 12 visits per calendar year without prior authorization $30 copay, deductible and coinsurance do not apply

In-Network: Covered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan $30 copay, deductible and coinsurance do not apply

In-Network: Not covered

In-Network: Inpatient: Deductible and coinsurance apply Outpatient: $30 copay, deductible and coinsurance do not apply

In-Network: Quit for Life Program - covered in full

Source statement: Routine Foot Care is listed in the source exclusions; review the qualifications.

In-Network: Covered in full

In-Network: Covered in full

Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions.

In-Network: Covered in full

Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions.

iht-2027-kaiser-plus-2500v

KP Plus 2500

Kaiser Foundation Health Plan of Washington Options, Inc.

PPO

2027-01-01

2027-12-31

BHT classification: N/A (similar to Gold)

No

No

Source answer: Yes. Preventive care and services indicated in chart starting on page 2.

Benefit details: 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 www.healthcare.gov/coverage/preventive-care-benefits.

In-Network: 4th quarter carryover does not apply

In-Network: Plan pays 70%, you pay 30%

In-Network: Deductible and coinsurance do not apply to office visits