Disclosure Form Part One (continued) 4215216.3.2.S000796606 embedded Durable Medical Equipment (DME) You Pay Base DME items as described in the EOC ............................................. No charge after Plan Deductible Supplemental DME items up to a $2,500 benefit limit per Accumulation Period as described in the EOC ..................................... No charge after Plan Deductible Mental Health Services You Pay Inpatient psychiatric hospitalization ........................................................ No charge after Plan Deductible Individual outpatient mental health evaluation and treatment ................ No charge after Plan Deductible Group outpatient mental health treatment .............................................. No charge after Plan Deductible Substance Use Disorder Treatment You Pay Inpatient detoxification ............................................................................ No charge after Plan Deductible Individual outpatient substance use disorder evaluation and treatment No charge after Plan Deductible Group outpatient substance use disorder treatment .............................. No charge after Plan Deductible Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ............... No charge after Plan Deductible Other You Pay Skilled nursing facility care (up to 100 days per benefit period) ............. No charge after Plan Deductible Prosthetic and orthotic devices as described in the EOC ...................... No charge after Plan Deductible Fertility Services (such as outpatient procedures or laboratory tests) as described in the EOC (oocyte retrievals limited to three per lifetime) ................................................................................................. the Cost Share you would pay if the Services were to treat any other condition 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).