DHMO 750 SC (TES)

Disclosure Form Part One Total Education Solutions Cust ID 233882 Member Services 800 464-4000 Home Region: Southern California 4/1/25 through 3/31/26 Principal benefits for Kaiser Permanente Deductible HMO Plan Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services you receive during the Accumulation Period until you reach the deductible amounts listed below. All payments you make toward your deductibles apply to the Plan Out-of-Pocket Maximum amounts listed below. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family Entire Family of two or of two or more Members more Members Plan Out-of-Pocket Maximum $3,000 $3,000 $6,000 Plan Deductible $750 $750 $1,500 Drug Deductible None None None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits ...... $30 per visit (Plan Deductible doesn’t apply) Most Physician Specialist Visits ............................................................. $40 per visit (Plan Deductible doesn’t apply) Routine physical maintenance exams, including well-woman exams .... No charge (Plan Deductible doesn’t apply) Well-child preventive exams (through age 23 months) .......................... No charge (Plan Deductible doesn’t apply) Routine eye exams with a Plan Optometrist .......................................... No charge (Plan Deductible doesn’t apply) Urgent care consultations, evaluations, and treatment .......................... $30 per visit (Plan Deductible doesn’t apply) Most physical, occupational, and speech therapy .................................. $30 per visit (Plan Deductible doesn’t apply) Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video or telephone .................................................................................. No charge (Plan Deductible doesn’t apply) Physician Specialist Visits by interactive video or telephone ................. No charge (Plan Deductible doesn’t apply) Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures .................. 20% Coinsurance after Plan Deductible Most immunizations (including the vaccine) ........................................... No charge (Plan Deductible doesn’t apply) Most X-rays and laboratory tests ............................................................ $10 per encounter (Plan Deductible doesn’t apply) Preventive X-rays, screenings, and laboratory tests as described in the EOC ................................................................................................ No charge (Plan Deductible doesn’t apply) MRI, most CT, and PET scans ............................................................... 20% Coinsurance up to a maximum of $150 per procedure (Plan Deductible doesn’t apply) Hospital Inpatient Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ..................................................................................................... 20% Coinsurance after Plan Deductible Emergency Services You Pay Emergency department visits ................................................................. 20% Coinsurance after Plan Deductible Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the emergency department Cost Share (see “Hospital Inpatient Services” for inpatient Cost Share) Ambulance Services You Pay Ambulance Services ............................................................................... $150 per trip (Plan Deductible doesn’t apply) Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy ................................. $10 for up to a 30-day supply (Plan Deductible doesn’t apply) Most generic (Tier 1) refills through our mail-order service ................. $20 for up to a 100-day supply (Plan Deductible doesn’t apply) (continues)