Disclosure Form Part One (continued) Prescription Drug Coverage You Pay Most brand-name items (Tier 2) at a Plan Pharmacy .......................... $30 for up to a 30-day supply (Plan Deductible doesn’t apply) Most brand-name (Tier 2) refills through our mail-order service ......... $60 for up to a 100-day supply (Plan Deductible doesn’t apply) Most specialty items (Tier 4) at a Plan Pharmacy ............................... 20% Coinsurance (not to exceed $250) for up to a 30-day supply (Plan Deductible doesn’t apply) Durable Medical Equipment (DME) You Pay DME items as described in the EOC ...................................................... 20% Coinsurance (Plan Deductible doesn’t apply) Mental Health Services You Pay Inpatient psychiatric hospitalization ........................................................ 20% Coinsurance after Plan Deductible Individual outpatient mental health evaluation and treatment ................ $30 per visit (Plan Deductible doesn’t apply) Group outpatient mental health treatment .............................................. $15 per visit (Plan Deductible doesn’t apply) Substance Use Disorder Treatment You Pay Inpatient detoxification ............................................................................ 20% Coinsurance after Plan Deductible Individual outpatient substance use disorder evaluation and treatment $30 per visit (Plan Deductible doesn’t apply) Group outpatient substance use disorder treatment .............................. $5 per visit (Plan Deductible doesn’t apply) Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ............... No charge (Plan Deductible doesn’t apply) Other You Pay Skilled nursing facility care (up to 100 days per benefit period) ............. 20% Coinsurance (Plan Deductible doesn’t apply) Prosthetic and orthotic devices as described in the EOC ...................... No charge (Plan Deductible doesn’t apply) Diagnosis and treatment of infertility and artificial insemination (such as outpatient procedures or laboratory tests) as described in the EOC ...................................................................................................... 50% Coinsurance (Plan Deductible doesn’t apply) Assisted reproductive technology (“ART”) Services ............................... Not covered This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Disclosure Form Part Two The Disclosure Form Part Two provides an overview of important features of your Health Plan membership, including how to obtain Services, principal exclusions, and important notices. To view or download a copy, go to kp.org/choosekp or call Member Services at 1-800-464-4000 (TTY users call 711). 4205799.13.1.S000759410 embedded