HEALTH PLAN BENEFIT SUMMARIES

KAISER PERMANENTE SMALL BUSINESS GROUP HEALTH PLAN BENEFIT SUMMARIES 1

The Colorado Division of Insurance may amend copayments, coinsurance and/or s. Please contact your broker or Kaiser Permanente sales representative for the most current information.

Table of Contents Introduction...2-3 HMO Plans...4-5 HMO Deductible/Coinsurance Plans...6-9 Basic and Standard HMO Plans...10-11 HSA-Qualified Deductible Plans...12-13 Point of Service Plans...14-15 Out-of-Area PPO Plans...16-17 1

EXPECT MORE FROM KAISER PERMANENTE MORE OPTIONS FOR COVERAGE MORE WAYS TO SAY YES It s an ongoing balancing act to find a quality health care solution that satisfies employees while helping your company meet its bottom line. More than ever, your workforce is looking to you for guidance and options. Open the door to choice and value for employees with Kaiser Permanente s expanded product portfolio. You can offer coverage options from three suites of products HMO, Preferred Provider Organization (PPO), and Point of Service (POS) insurance plans 1 so you can satisfy everyone, including those who need more choice and affordable care. No matter which plan or combination of plans you select, you can expect Kaiser Permanente to be your employees total health advocate. They can take advantage of wellness programs to stay healthy, extensive online resources to empower them to make more informed health care decisions, and a broad range of preventive services to help stop problems before they start. THREE PRODUCT SUITES ONE SINGLE SOLUTION THE KAISER PERMANENTE HMO product suite With predictable copayments and no s, Kaiser Permanente s traditional HMO products offer the best value for the health care dollar. Our Deductible/Coinsurance HMO plans offer a transition to cost sharing with lower monthly premiums, s for some services, set copays for routine care, and preventive care at no cost. And our HSA-Qualified Deductible HMO plans give you more control over their health care dollars by offering access to taxadvantaged savings that can be used to pay for care. 2 ADD AN HRA TO YOUR KAISER PERMANENTE MEDICAL PLAN FOR SAVINGS AND CONTROL Combining a Health Reimbursement Arrangement (HRA) with a Kaiser Permanente Deductible HMO or HSA-Qualified Deductible HMO plan allows employers to maximize premium savings while limiting employee exposure. Check out these HRA benefits: WHAT IS A HEALTH REIMBURSEMENT ARRANGEMENT? A Health Reimbursement Arrangement (HRA) is an IRS approved (Section 105), employer funded plan whereby employers may reimburse participants for certain eligible health care expenses. Kaiser Permanente s HRA allow you to increase your plan and realize substantial premium savings. The HRA allows you to assume some or all of the employee s Kaiser Permanente covered exposure. The result is lower plan premiums which you may retain or pass along to your participants. In addition, by helping your employees pay for some expenses, you provide what is perceived as a valuable medical benefit. HRA premium savings almost always outweigh HRA expenses, netting you substantial benefit cost savings. 2

THE KAISER PERMANENTE POS product suite MORE THAN YOU EXPECT POS plans enable your employees to balance cost, choice, and coverage. These plans appeal to those who like the ease and convenience of a traditional HMO for some services but already have an established relationship with a physician outside the Kaiser Permanente network. With MultiChoice, employees get a wide range of options and you still have a single carrier. 3 Kaiser Permanente s MulitChoice SM POS plans give employees the choice of Colorado Permanente Medical Group (CPMG) or affiliated physicians; a physician from Private Healthcare Systems (PHCS), our preferred provider network, other Kaiser Permanente contracted providers, or any other licensed physician. If they select a CPMG, PHCS, or other contracted doctor, their copays, s, and out-of-pocket maximums will be the same. And by selecting the Kaiser Permanente network, they ll get a health care team that works together to manage their total health for the long run. And of course, as a Kaiser Permanente member, they get all the online tools and resources to help them stay in charge of their health. EXPANDED CHOICE WITH SAVINGS To add even more choice, POS employees can mix and match. For example, they can keep the pediatrician their kids have been seeing since birth and pay slightly higher rates. To save on prescription drugs, they can have their formulary prescriptions filled at Kaiser Permanente even if their non-kaiser Permanente pediatrician writes the order. 4 THE KAISER PERMANENTE PPO product suite CHOOSE FLEXIBLE COVERAGE With PPO plans, your employees have access to a broad, nationwide provider Private Healthcare Systems (PHCS Network). In addition, PPO members can receive care from any licensed health care provider in the nation without a referral. 5 They still receive Kaiser Permanente value-added services like discounts on affinity products and online tools, and all plans include Kaiser Permanente Healthy Solutions programs. Our PPO plans let employees keep their doctor they can choose a doctor within our provider network or pay a higher coinsurance and opt for any licensed provider. HSA qualified PPO plans, featuring an array of annual / coinsurance combinations, combine the freedom to choose any provider with tax advantages and lower premiums. A SINGLE SOLUTION AT YOUR FINGERTIPS Building a benefits solution that works for you and your employees is easier than ever. We offer three suites of health care products with alternative funding arrangements and ease of administration with one monthly bill and one point of contact. Thank you for considering Kaiser Permanente, your single-source solution. Call your broker or a Kaiser Permanente sales representative today at 303-338-3700 in the Denver/Boulder area or 719-867-2100 in Southern Colorado. Or log on to employers.kp.org for more information. 1 The HMO plan and the in-network portion of the POS plan are underwritten by Kaiser Foundation Health Plan (KFHP). Kaiser Permanente Insurance Company (KPIC) underwrites the out-of-network tier of the POS and PPO plans. Please contact your broker or your sales representative to see if you qualify for these funding options. 2 The tax references in this brochure relate to federal income tax only. Consult with a financial or tax advisor for more information about state income tax laws. 3 If employees receive care from any other licensed provider, they must make their own financial arrangements with the provider. They are responsible for paying the bills and completing any necessary claim forms. Employees must meet a and pay the established coinsurance. If the provider bills for more than the maximum allowable charge, the employee will be responsible for paying the amount over the maximum allowable charge. 4 Prescriptions must be on the Kaiser Permanente formulary. 5 If employees receive care from any other licensed provider, they must make their own financial arrangements with the provider. They are responsible for paying the bills and completing any necessary claim forms. Employees must meet a and pay the established coinsurance. If the provider bills for more than the maximum allowable charge, the employee will be responsible for paying the amount over the maximum allowable charge. 6 KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc. 3

HMO Plan Benefit Classic 30 HMO Deductible (per calendar year) No Deductible Family 1 No Deductible Out-of-pocket (OOP) maximum per calendar year $3,000 Family 1 $7,500 Medical office visits Preventive care 2 Primary care $30 each visit Specialty care $40 each visit Outpatient or same-day surgery $150 each visit Hearing exams $30 each visit Eye exams for glasses performed by an Optometrist $30 each visit Diagnostic services Lab tests Diagnositc X-rays Therapeutic X-rays $40 each visit Special procedures such as CT, PET, MRI $100 per procdure Hospitalization $1,000 per admission/no limit on the number of covered hospital days After-hours care Received at designated facilities Emergency care Received at a facility designated by Kaiser Permanente $75 each visit $100 each visit, waived if admitted as inpatient Emergency care from non-plan facilities and providers $100 per approved claim, waived if admitted as inpatient Ambulance service When use of other means of transportation would adversely affect your condition Maternity care Prenatal and postpartum visits 20% coinsurance, up to $500 per trip Delivery See "hospitalization" Prescriptions Up to a 30-day supply, obtained from a Kaiser Permanente pharmacy Mail order service: up to a 90-day supply for two copays $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred; 20% coinsurance for specialty drugs including self injectibles, up to a max. $250 per drug 1 For Families, each family member is responsible for meeting his/her Individual OOP amount, until the family OOP is met. 2 The copay or coinsurance for certain preventive services may differ from the copay listed above. 4

Classic 35A HMO Classic 40 HMO No Deductible No Deductible No Deductible No Deductible $4,000 $4,000 $8,000 $8,000 $30 each visit $40 each visit $50 each visit $75 each visit $200 each visit $200 each visit $30 each visit $40 each visit $30 each visit $40 each visit $50 each visit $75 each visit $100 per procdure $250 per procdure 20% coinsurance/no limit on the number of covered hospital days $1,000 per day for days 1-4 per admission/no limit on the number of covered hospital days $100 each visit $125 each visit $200 each visit, waived if admitted as inpatient $200 each visit, waived if admitted as inpatient $200 per approved claim, waived if admitted as inpatient $200 per approved claim, waived if admitted as inpatient 20% coinsurance, up to $500 per trip 20% coinsurance, up to $500 per trip See "hospitalization" $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred; 20% coinsurance for specialty drugs including self injectibles, up to a max. $250 per drug See "hospitalization" $250 pharmacy per individual; $15 copay generic; $50 copay brand-name, 50% coinsurance non-preferred; 20% coinsurance for specialty drugs including self injectibles, up to a max. $250 per drug 5

Deductible/Coinsurance HMO Plans Benefit Ded/Co HMO 500D Ded/Co HMO 750D Ded/Co HMO 1000D Deductible 1 (per calendar year) $500 $750 $1,000 Family 2 $1,500 $2,250 $3,000 Out-of-pocket (OOP) maximum per calendar year 3 $2,500 $2,500 $3,000 Family 2 $5,000 $5,000 $6,000 Medical office visits Preventive care 4 Primary care 5 Specialty care 5 Outpatient or same-day surgery Hearing exams Eye exams for glasses performed by an Optometrist Diagnostic services Lab tests Diagnositc X-rays Therapeutic X-rays Special procedures such as CT, PET, MRI Hospitalization After-hours care 5 Received at designated facilities Emergency care Received at a facility designated by Kaiser Permanente Received from non-plan facilities and providers Ambulance service When use of other means of transportation would adversely affect your condition Maternity care Prenatal and postpartum visits 20% coinsurance, up to $500 per trip; not subject to 20% coinsurance, up to $500 per trip; not subject to 20% coinsurance, up to $500 per trip; not subject to Delivery See hospitalization See hospitalization See hospitalization Prescriptions Up to a 30-day supply, obtained from a Kaiser Permanente pharmacy Mail order service: up to a 90-day supply for two copays No ; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $100 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug 6 1 All benefits are subject to s if applicable, except where noted. 2 For Families, each family member is responsible for meeting the his/her Individual Deductible/OOP until the family OOP is met. 3 Excludes s, copays, and prescriptions. 4 The copay or coinsurance for certain preventive services may differ from the copay listed above.

Deductible/Coinsurance HMO Plans Ded/Co HMO 1200D Ded/Co HMO 1500D Ded/Co HMO 2000D Ded/Co HMO 2500D $1,200 $1,500 $2,000 $2,500 $3,600 $4,500 $6,000 $7,500 $2,500 $4,500 $4,000 $5,000 $5,000 $9,000 $8,000 $10,000 20% coinsurance, up to $500 per trip; not subject to 20% coinsurance, up to $500 per trip; not subject to 20% coinsurance, up to $500 per trip; not subject to 20% coinsurance, up to $500 per trip; not subject to See hospitalization See hospitalization See hospitalization See hospitalization $100 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $100 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug 5 Procedures during visit are billed at coinsurance level after. 6 Pharmacy s do not apply to annual s; copays do not apply to out-of-pocket maximum. 7 After pharmacy. 8 Member pays 50% of retail price for non-preferred drugs. 7

Deductible/Coinsurance HMO Plans Deductible 1 (per calendar year) Benefit $3,000 Family 2 $9,000 Ded/Co HMO 3000D Out-of-pocket (OOP) maximum per calendar year 3 $6,000 Family 2 $12,000 Medical office visits Preventive care 4 Primary care 5 Specialty care 5 Outpatient or same-day surgery Hearing exams Eye exams for glasses performed by an Optometrist Diagnostic services Lab tests Diagnositc X-rays Therapeutic X-rays Special procedures such as CT, PET, MRI Hospitalization After-hours care 5 Received at designated facilities Emergency care Received at a facility designated by Kaiser Permanente Received from non-plan facilities and providers Ambulance service When use of other means of transportation would adversely affect your condition 20% coinsurance, up to 500 per trip; not subject to Maternity care Prenatal and postpartum visits Delivery See hospitalization Prescriptions Up to a 30-day supply, obtained from a Kaiser Permanente pharmacy Mail order service: up to a 90-day supply for two copays $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug 1 All benefits are subject to s if applicable, except where noted. 2 For Families, each family member is responsible for meeting the his/her Individual Deductible/OOP until the family OOP is met. 3 Excludes s, copays, and prescriptions. 4 The copay or coinsurance for certain preventive services may differ from the copay listed above. 8

Ded/Co HMO 4000D Ded/Co HMO 5000D Ded/Co HMO 2000F $4,000 $5,000 $2,000 $12,000 $15,000 $6,000 $8,000 $10,000 $5,500 $16,000 $20,000 $11,000 30% coinsurance, after 30% coinsurance, after 30% coinsurance, after 30% coinsurance, after 30% coinsurance, after 30% coinsurance, after 30% coinsurance, after 20% coinsurance, up to $500 per trip; not subject to 20% coinsurance, up to $500 per trip; not subject to 30% coinsurance, up to $500 per trip not subject to See hospitalization See hospitalization See hospitalization $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $200 6 /Person; $15 copay generic; $30 copay preferred brand name; 50% coinsurance non-preferred 7,8 ; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug 5 Procedures during visit are billed at coinsurance level after. 6 Pharmacy s do not apply to annual s; copays do not apply to out-of-pocket maximum. 7 After pharmacy. 8 Member pays 50% of retail price for non-preferred drugs. 9

Basic and Standard HMO Plans Deductible (per calendar year) Benefit No Deductible HMO Basic Limited Mandate Health Benefit Plan for Colorado Family 1 No Deductible Out-of-pocket (OOP) maximum per calendar year 2 $8,000 Family 1 $16,000 Medical office visits Preventive care $40 each visit Primary care $40 each visit Specialty care $60 each visit Outpatient or same-day surgery $500 each visit Hearing exams $40 each visit Eye exams for glasses performed by an Optometrist Diagnostic services Lab tests Not Covered Diagnositc X-rays Therapeutic X-rays Special procedures such as CT, PET, MRI Hospitalization After-hours care Received at designated facilities Emergency care Received at a facility designated by Kaiser Permanente Received from non-plan facilities and providers Ambulance service When use of other means of transportation would adversely affect your condition Maternity care Prenatal and postpartum visits $300 copayment $1,000 per day up to $4,000 per admission; no limit on # of days $100 each visit; procedures received during visit are included $250 each visit, waived if admitted $250 each visit, waived if admitted 30% copay Applicable copays for each type of service Delivery See hospitalization Prescriptions Up to a 30-day supply, obtained from a Kaiser Permanente pharmacy Mail order service: up to a 90-day supply for two copays $150 annual /Person, does not apply to out-of-pocket maximum; $20 copay generic; $50 copay preferred; $70 copay non-preferred 3 10

HMO Standard Health Benefit Plan for Colorado No Deductible No Deductible $4,000 $8,000 $30 each visit $30 each visit $50 each visit $250 each visit $30 each visit Not Covered $150 copayment $500 per day up to $2,000 per admission; no limit on # of days $75 each visit; procedures received during visit are included $150 each visit, waived if admitted $150 each visit, waived if admitted 20% copay 1 For Families, individual family members are responsible for meeting the Family Deductible and/or OOP, only up to the Individual Deductible and/or OOP amount. 2 Excludes pharmacy s and prescriptions. 3 After pharmacy. Applicable copays for each type of service See hospitalization No, $10 copay generic; $40 copay preferred; $60 copay non-preferred 11

HSA-Qualified Deductible HMO Plans Deductible 1 (per calendar year) Benefit Ded/Co HSA 1500 Ded/Co HSA 2000 $1,500 $2,000 Family 2 $3,000 $4,000 Out-of-pocket (OOP) maximum per calendar year 1 Equals Deductible Equals Deductible Family 2 Equals Deductible Equals Deductible Medical office visits Preventive care 3 Primary care after after Specialty care after after Outpatient or same-day surgery after after Hearing exams after after Eye exams for glasses performed by an Optometrist Diagnostic services Lab tests after ; does not include hardware after after is met; does not include hardware after Diagnositc X-rays after after Therapeutic X-rays after after Special procedures such as CT, PET, MRI after after Hospitalization after after After-hours care Received at designated facilities Emergency care Received at a facility designated by Kaiser Permanente after after after after Received from non-plan facilities and providers after after Ambulance service When use of other means of transportation would adversely affect your condition Maternity care Prenatal and postpartum visits after after after after Delivery See hospitalization See hospitalization Prescriptions Up to a 30-day supply, obtained from a Kaiser Permanente pharmacy Mail order service: up to a 90-day supply for two copays after after 1 Deductibles apply toward out-of-pocket maximum. 2 For families, the individual /OOP does not apply. The family /OOP can be met by one family member or by a combination of family members. 12

HSA-Qualified Deductible HMO Plans Ded/Co HSA 3000 Ded/Co HSA 5000 $3,000 $5,000 $6,000 $10,000 Equals Deductible Equals Deductible Equals Deductible Equals Deductible after after after after after after after after after ; does not include hardware after ; does not include hardware after after after after after after after after after after after after after after after after after after after after See hospitalization after See hospitalization after 3 The copay or coinsurance for certain preventive services may differ from the copay listed above. 13

Point of Service (POS) Plans MultiChoice POS 1500D Benefit In-Network Preferred Provider Network Out-of-Network Deductible 1 (per calendar year) $1,500 $1,500 6 $3,500 Family $4,500 $4,500 6 $10,500 Out-of-pocket (OOP) maximum per calendar year 2 $5,000 $5,000 6 $10,000 Family $10,000 $10,000 6 $20,000 Medical office visits Preventive care 3,4 50% coinsurance Primary care 5 $40 copay $40 copay 50% coinsurance Specialty care 5 $50 copay $50 copay 50% coinsurance Outpatient or same-day surgery Hearing exams $40 copay Not covered Not covered Eye exams for glasses performed by an Optometrist Diagnostic services Lab tests $40 copay $40 copay 50% coinsurance 20% coinsurance 50% coinsurance Diagnositc X-rays 20% coinsurance 20% coinsurance 50% coinsurance Therapeutic X-rays 20% coinsurance 20% coinsurance 50% coinsurance Special procedures such as CT, PET, MRI 20% coinsurance 20% coinsurance 50% coinsurance Hospitalization 20% coinsurance 20% coinsurance 50% coinsurance After-hours care 5 Received at designated facilities $50 copay $50 copay 50% coinsurance Emergency care 20% coinsurance Covered by HMO Covered by HMO Ambulance service When use of other means of transportation would adversely affect your condition Maternity care Prenatal and postpartum visits 20% coinsurance, up to $500 per trip Covered by HMO Covered by HMO 50% coinsurance Delivery 20% coinsurance 20% coinsurance 50% coinsurance Prescriptions Up to a 30-day supply, obtained from a Kaiser Permanente pharmacy Mail order service: up to a 90-day supply for two copays $20 copay generic; $30 copay preferred brand name; $45 copay non-preferred; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $25 copay generic; $40 copay preferred brand name; $55 copay non-preferred; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $25 copay generic; $40 copay preferred brand name; $55 copay non-preferred; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug 1 Benefits apply after except for copays and prescriptions. 2 Excludes s and copays. 3 The copay or coninsurance for certain preventive services may differ from the copay listed above. 4 Preventive care includes adult preventive care exams and screenings, well-woman care, immunizations, well-child care (exams and immunizations in accordance with medical guidelines), and colorectal cancer screenings. The does not apply to preventive services unless they are intended to treat an existing illness, injury, or condition. Non-preventive services received during a preventive exam may be subject to the. 14

Point of Service (POS) Plans MultiChoice POS 2000F In-Network Preferred Provider Network Out-of-Network $2,000 $2,000 6 $3,500 $6,000 $6,000 6 $10,500 $5,000 $5,000 6 $10,000 $10,000 $10,000 6 $20,000 50% coinsurance $40 copay $40 copay 50% coinsurance $50 copay $50 copay 50% coinsurance $40 copay Not covered Not covered $40 copay $40 copay 50% coinsurance 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance $50 copay $50 copay 50% coinsurance 30% coinsurance Covered by HMO Covered by HMO 30% coinsurance, up tp $500 per trip Covered by HMO Covered by HMO 50% coinsurance 30% coinsurance 30% coinsurance 50% coinsurance $20 copay generic; $30 copay brand name; $45 copay non-preferred; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $25 copay generic; $40 copay brand name; $55 copay non-preferred; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug $25 copay generic; $40 copay brand name; $55 copay non-preferred; 20% coinsurance for specialty drugs including self injectibles up to a max. $250 per drug 5 Procedures during visit are billed at coinsurance level after. 6 Tier 2 /OOP accumulations contribute to Tier 1 / OOP accumulations. 15

Out-of-Area Preferred Provider Organization (PPO) Plans OOA Plan SP01 Benefit CLASSIC OOA Preferred Network Out-of-Network Deductible (per calendar year) $200 $750 $1,000 Family $500 $2,250 $3,000 Out-of-pocket (OOP) maximum per calendar year $2,500 $3,000 $6,000 Family $4,500 $7,500 $15,000 Medical office visits 20% coinsurance, Preventive care 1 waived Primary care Specialty care Outpatient or same-day surgery Hearing exams Eye exams for glasses performed by an Optometrist Diagnostic services Lab tests Diagnositc X-rays Therapeutic X-rays Special procedures such as CT, PET, MRI Hospitalization After-hours care Emergency care Ambulance service When use of other means of transportation would adversely affect your condition Maternity care Prenatal and postpartum visits Delivery Prescriptions 20% coinsurance for up to a 30-day supply; individual of $50, family of $100 $0 per visit copay; limited services available see certificate; waived 40% coinsurance; limited services available; waived. $20 each visit 1,2 $30 each visit 1,2 ; precertification required Not covered $20 each visit ; precertification required Not covered $30 each visit 1,2 ; limited to a maximum $1,000 per occurrence combined with out-of-network $15 copay generic; $30 copay preferred brand name, limited to a 30-day supply at participating pharmacies; 20% coinsurance selfadministered injectibles ; limited to a maximum $1,000 per occurrence combined with out-of-network 40% coinsurance 50% coinsurance, no s at non- MedImpact pharmacies; claim must be filed with MedImpact 1 Not subject to. 2 Procedures during visit are billed at coinsurance level after. 16

Out-of-Area Preferred Provider Organization (PPO) Plans OOA Plan SP02 OOA Plan SP03 Preferred Network Out-of-Network Preferred Network Out-of-Network $1,000 $1,500 $2,000 $3,000 $3,000 $4,500 $6,000 $9,000 $4,000 $8,000 $6,000 $12,000 $10,000 $20,000 $15,000 $30,000 $0 per visit copay; limited services available see certificate; waived. 50% coinsurance; limited services available; waived. $30 each visit 1,2 $50 each visit 1,2 ; precertification required ; precertification required $0 per visit copay; limited services available see certificate; waived. 50% coinsurance; limited services available; waived. $30 each visit 1,2 $50 each visit 1,2 ; precertification required ; precertification required Not covered Not covered Not covered Not covered $30 each visit $30 each visit $50 each visit 1,2 $50 each visit 1,2 ; limited to a maximum $1,000 per occurrence combined with out-of-network ; limited to a maximum $1,000 per occurrence combined with out-of-network ; limited to a maximum $1,000 per occurrence combined with out-of-network ; limited to a maximum $1,000 per occurrence combined with out-of-network 50% coinsurance 50% coinsurance $15 copay generic; $30 copay preferred brand name, limited to a 30-day supply at participating pharmacies; 20% coinsurance self-administered injectibles 50% coinsurance, no s at non- MedImpact pharmacies; claim must be filed with MedImpact $100 per person (cross-accumulates with outof-network) per calendar year. Then $15 copay generic; $30 copay preferred brand name, limited to a 30-day supply at participating pharmacies. 20% coinsurance self-administered injectibles $100 per person (cross-accumulates with preferred network) per calendar year; then 50% coinsurance, no s at non-medimpact pharmacies; claim must be filed with MedImpact 17

The State of Colorado defines a small employer as an employer with one to 50 eligible employees. By state regulation, rates are based on the age and family size of your employees who enroll in a Kaiser Permanente plan as well as Medicare integration, as applicable. Certain groups may be impacted by Medicare integration, in which case the premiums associated with those members vary dependent upon which payor (Medicare or Kaiser Permanente) is primary and which is secondary. If the group has 10 or more eligible employees, it is also subject to Standard Industrial Classification (SIC) rating factor and may elect age banded or composite rates. Premiums and any annual rate increases are determined by the expected costs to the Health Plan and are applied equally to all small employer groups. Any small employer group meeting all provisions of the signed agreement will have the right to renew. Colorado insurance law requires all carriers in the small group market to issue any health benefit plan it markets in Colorado to small employers of 2-50 employees, including a Basic or Standard Health Benefit Plan, upon the request of a small employer to the entire small group, regardless of the health status of any of the individuals in the group. Business Groups of One cannot be rejected under a Basic or Standard Health Benefit Plan during open enrollment periods as specified by law. Colorado State law requires an Access Plan describing Kaiser Permanente s network of providers and services be available. To obtain a copy, call 303-338-3800 in Denver/Boulder; or 719-867-2100 in Southern Colorado. Colorado law requires carriers to make available a Colorado Health Plan Description Form, which is intended to facilitate comparison of health plans. The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan. The carrier also must provide the form, upon oral or written request, within three (3) business days, to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier. IMPORTANT: These are not federally qualified health benefit plans. This is a summary of coverage for eligible members that only briefly summarizes the major provisions of the Agreement between Kaiser Permanente and you or your group. There are services or conditions that are excluded from coverage or that may only be covered under certain circumstances. Further information may be obtained by contacting Kaiser Permanente or by referring to your Evidence of Coverage or Certificate of Insurance. In the event of ambiguity and/or conflict between this synopsis and/or the Evidence of Coverage or Certificate of Insurance., the Evidence of Coverage or Certificate of Insurance shall control. 10_DC_SG_BenSum 60041838_DS_10