These electronic documents must be used as provided, without additions, deletions, or other modifications.

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Kaiser Foundation Health Plan, Inc. Electronic Documents Policy

This policy document constitutes the explicit, written permission of Kaiser Foundation Health Plan, Inc., (Health Plan) for the Purchaser to use the accompanying Health Plan Enrollment and Member electronic documents under the following conditions:

These electronic documents must be used as provided, without additions, deletions, or other modifications.

These electronic documents are being provided in English. Translation of these documents by any person/organization other than by Health Plan (or certified translation agencies authorized by Health Plan) is prohibited. Please contact your Health Plan account representative to learn which documents are available in other languages.

These electronic documents may be posted to Purchaser Web sites.

Health Plan will provide updated versions of these electronic documents if there are

substantive language changes. Purchasers must transfer the updated versions to their sites as soon as reasonably possible, but not later than 30 days after receipt of an updated document.

The Disclosure Form (DF) is subject to change. Health Plan will provide substantive DF language changes electronically to Purchasers. It is the Purchaser's responsibility to ensure that all changes are provided to employees. All electronic DF documents include a footnote containing an original issuance date to ensure accurate tracking.

If you have questions about our Electronic Documents Policy, or questions about a specific request for an electronic document, please contact your account representative for

assistance.

Kaiser Foundation Health Plan, Inc. California Division

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Kaiser Foundation Health Plan, Inc., Southern California Region continues

231396 ASCIP- MANHATTAN BEACH USD

Summary of Benefits for

Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/15—9/30/16)

The Services described below are covered only if all of the following conditions are satisfied:

• The Services are Medically Necessary and in accord with Medicare guidelines

• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive

the Services from Plan Providers inside our Southern California Region Service Area, except where specifically noted to the contrary in the Evidence of Coverage (EOC)

Accumulation Period

The Accumulation Period for this plan is 1/1/15 through 12/31/15 (calendar year).

Plan Out-of-Pocket Maximum

For Services subject to the maximum, you will not pay any more Cost Share for the rest of the calendar year if the Copayments and Coinsurance you pay for those Services add up to one of the following amounts:

For self-only enrollment (a Family of one Member) ... $1,500 per calendar year For any one Member in a Family of two or more Members ... $1,500 per calendar year For an entire Family of two or more Members... $3,000 per calendar year

Plan Deductible None

Professional Services (Plan Provider office visits) You Pay

Most Primary Care Visits for evaluations and treatment ... No charge Most Specialty Care Visits for consultations, evaluations, and

treatment... No charge Annual Wellness visit and the "Welcome to Medicare" preventive

visit ... No charge Routine physical exams ... No charge Routine eye exams with a Plan Optometrist ... No charge Hearing exams... No charge Urgent care consultations, evaluations, and treatment ... No charge Physical, occupational, and speech therapy ... No charge

Outpatient Services You Pay

Outpatient surgery and certain other outpatient procedures... No charge Allergy injections (including allergy serum) ... No charge Most immunizations (including the vaccine)... No charge Most X-rays, annual mammograms, and laboratory tests... No charge Manual manipulation of the spine ... No charge

Hospitalization Services You Pay

Room and board, surgery, anesthesia, X-rays, laboratory tests,

and drugs... No charge

Emergency Health Coverage You Pay

Emergency Department visits ... No charge

Ambulance Services You Pay

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continued

Kaiser Foundation Health Plan, Inc., Southern California Region 4190920.12.2.S000425302

Prescription Drug Coverage You Pay

Most covered outpatient items in accord with our drug formulary

guidelines... $5 for up to a 100-day supply

Durable Medical Equipment (DME) You Pay

Covered durable medical equipment for home use ... No charge

Mental Health Services You Pay

Inpatient psychiatric care ... No charge Individual outpatient mental health evaluation and treatment ... No charge Group outpatient mental health treatment ... No charge

Chemical Dependency Services You Pay

Inpatient detoxification ... No charge Individual outpatient chemical dependency evaluation and

treatment... No charge Group outpatient chemical dependency treatment ... No charge

Home Health Services You Pay

Home health care (part-time, intermittent) ... No charge

Other You Pay

Eyeglasses or contact lenses every 24 months ... Amount in excess of $150 Allowance Skilled nursing facility care (up to 100 days per benefit period) ... No charge

External prosthetic and orthotic devices ... No charge Ostomy and urological supplies ... No charge

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. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

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60152215

2014 Summary

of Benefits

Original Medicare and Kaiser Permanente

Senior Advantage (HMO) Group Plan

Including Medicare Part D Prescription Drug Benefit Information Kaiser Foundation Health Plan, Inc.

Northern and Southern California Regions A nonprofit corporation

Health Maintenance Organization (HMO) January 1, 2014, through December 31, 2014

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I-1

Section I – Introduction to Summary of Benefits

Thank you for your interest in Kaiser Permanente Senior Advantage (HMO). Our plan is offered by KAISER FOUNDATION HP, INC. which is also called Kaiser Permanente, a Medicare Advantage Health Maintenance Organization (HMO) that contracts with the Federal government. This Summary of Benefits shows the benefits available to a Medicare beneficiary under Original (Fee-for-Service) Medicare. As a member of Kaiser Permanente Senior Advantage (HMO) who receives coverage through an employer or trust fund, you may receive additional benefits. To get a complete list of your Kaiser Permanente Senior Advantage (HMO) benefits, please refer to your Evidence of Coverage (EOC). Contact your employer or trust fund or call Kaiser Permanente Senior Advantage (HMO) and ask for the “Evidence of Coverage.”

You have choices in your health care

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like Kaiser Permanente Senior Advantage (HMO), which is made available through your employer or trust fund. However, if you enroll in Original Medicare alone, you may endanger the coverage you receive through your employer or trust fund, and your benefits may be reduced. For information about the benefits available through your employer or trust fund, please see your Evidence of Coverage. No matter what you decide, you are still in the Medicare Program.

Your employer or trust fund may restrict when you may join or leave its plan. Usually this is connected to your employer or trust fund's annual enrollment period. Please call your employer or trust fund for more information about enrollment periods.

How can I compare my options?

You can compare Kaiser Permanente Senior Advantage (HMO) and the Original Medicare Plan using this Summary of Benefits and the Kaiser Permanente Senior Advantage (HMO) Summary of Benefits. This Summary of Benefits lists only benefits covered by Original Medicare.

The Kaiser Permanente Senior Advantage (HMO) Summary of Benefits lists the Kaiser Permanente Senior Advantage (HMO) benefits you receive through your employer or trust fund. As a member who receives Kaiser Permanente Senior Advantage (HMO) coverage through an employer or trust fund, you will receive all of the benefits that the Original Medicare plan offers, plus additional benefits purchased for you by your employer or trust fund, which may change from year to year.

Where is Kaiser Permanente Senior Advantage (HMO) available?

Northern California

In Northern California, the service area for this plan includes: Alameda, Amador*, Contra Costa, El Dorado*, Fresno*, Kings*, Madera*, Marin, Mariposa*, Napa*, Placer*, Sacramento, San

Francisco, San Joaquin, San Mateo, Santa Clara*, Solano, Sonoma*, Stanislaus, Sutter*, Tulare*, Yolo*, and Yuba* Counties, CA. You must live in one of these areas to join the plan.

* denotes partial county

Amador County: 95640, 95669.

El Dorado County: 95613–14, 95619, 95623, 95633–35, 95651, 95664, 95667, 95672, 95682, 95762.

Fresno County: 93242, 93602, 93606–07, 93609, 93611–13, 93616, 93618–19, 93624–27, 93630–31, 93646, 93648–52, 93654, 93656–57, 93660, 93662, 93667–68, 93675, 93701–12,

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I-2 93714–18, 93720–30, 93737, 93740–41, 93744–45, 93747, 93750, 93755, 93760–61, 93764–65, 93771–79, 93786, 93790–94, 93844, 93888. Kings County: 93230, 93232, 93242, 93631, 93656. Madera County: 93601–02, 93604, 93614, 93623, 93626, 93636–39, 93643–45, 93653, 93669, 93720. Mariposa County: 93601, 93623, 93653. Napa County: 94503, 94508, 94515, 94558–59, 94562, 94567, 94573–74, 94576, 94581, 94589–90, 94599, 95476. Placer County: 95602–04, 95626, 95648, 95650, 95658, 95661, 95663, 95668, 95677–78, 95681, 95692, 95703, 95722, 95736, 95746–47, 95765.

Santa Clara County: 94022–24, 94035, 94039–43, 94085–89, 94301–06, 94309, 94550, 95002, 95008–09, 95011, 95013–15, 95020–21, 95026, 95030–33, 95035–38, 95042, 95044, 95046, 95050–56, 95070–71, 95076, 95101, 95103, 95106, 95108–13, 95115–36, 95138–41, 95148, 95150–61, 95164, 95170, 95172–73, 95190–94, 95196. Sonoma County: 94515, 94922–23, 94926–28, 94931, 94951–55, 94972, 94975, 94999, 95401–07, 95409, 95416, 95419, 95421, 95425, 95430–31, 95433, 95436, 95439, 95441–42, 95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471–73, 95476, 95486–87, 95492. Sutter County: 95626, 95645, 95648, 95659, 95668, 95674, 95676, 95692, 95836–37. Tulare County: 93238, 93261, 93618, 93631, 93646, 93654, 93666, 93673. Yolo County: 95605, 95607, 95612, 95616–18, 95645, 95691, 95694–95, 95697–98, 95776, 95798–99. Yuba County: 95692, 95903, 95961. Southern California

In Southern California, the service area for this plan includes: Kern*, Los Angeles*, Orange, Riverside*, San Bernardino*, San Diego*, and Ventura* Counties, CA. You must live in one of these areas to join the plan.

* denotes partial county

Kern County: 93203, 93205–06, 93215–16, 93220, 93222, 93224–26, 93238, 93240–41, 93243, 93250–52, 93263, 93268, 93276, 93280, 93285, 93287, 93301–09, 93311–14, 93380, 93383–90, 93501–02, 93504–05, 93518–19, 93531, 93536, 93560–61, 93581.

Los Angeles County: 90001–84, 90086–91, 90093–96, 90099, 90101, 90189, 90201–02, 90209–13, 90220–24, 90230–33, 90239–42, 90245, 90247–51, 90254–55, 90260–67, 90270, 90272, 90274–75, 90277–78, 90280, 90290–96, 90301–12, 90401–11, 90501–10, 90601–10, 90623, 90630–31, 90637–40, 90650–52, 90660–62, 90670–71, 90701–03, 90706–07, 90710–17, 90723, 90731–34, 90744–49, 90755, 90801–10, 90813–15, 90822, 90831–35, 90840, 90842, 90844, 90846–48, 90853, 90895, 90899, 91001, 91003, 91006–12, 91016–17, 91020–21, 91023–25, 91030–31, 91040–43, 91046, 91066, 91077, 91101–10, 91114–18, 91121, 91123–26, 91129, 91182, 91184–85, 91188–89, 91199, 91201–10, 91214, 91221–22, 91224–26, 91301–11, 91313, 91316, 91321–22, 91324–31, 91333–35, 91337, 91340–46, 91350–57, 91361–62, 91364–65, 91367, 91371–72, 91376, 91380–87, 91390, 91392–96, 91401–13, 91416, 91423, 91426, 91436, 91470, 91482, 91495–96, 91499, 91501–08, 91510, 91521–23, 91526, 91601–12, 91614–18, 91702, 91706, 91709, 91711, 91714–16, 91722–24, 91731–35, 91740–41, 91744–50, 91754–56, 91765–73, 91775–76, 91778, 91780, 91788–93, 91801–04, 91896, 91899, 93243,

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I-3 93510, 93532, 93534–36, 93539, 93543–44, 93550–53, 93560, 93563, 93584, 93586, 93590–91, 93599. Riverside County: 91752, 92201–03, 92210–11, 92220, 92223, 92230, 92234–36, 92240–41, 92247–48, 92253, 92255, 92258, 92260–64, 92270, 92276, 92282, 92320, 92324, 92373, 92399, 92501–09, 92513–19, 92521–22, 92530–32, 92543–46, 92548, 92551–57, 92562–64, 92567, 92570–72, 92581–87, 92589–93, 92595–96, 92599, 92860, 92877–83.

San Bernardino County: 91701, 91708–10, 91729–30, 91737, 91739, 91743, 91758–59, 91761–64, 91766, 91784–86, 91792, 92305, 92307–08, 92313–18, 92321–22, 92324–26, 92329, 92331, 92333–37, 92339–41, 92344–46, 92350, 92352, 92354, 92357–59, 92369, 92371–78, 92382, 92385–86, 92391–95, 92397, 92399, 92401–08, 92410–13, 92415, 92418, 92423, 92427, 92880.

San Diego County: 91901–03, 91908–17, 91921, 91931–33, 91935, 91941–47, 91950–51, 91962–63, 91976–80, 91987, 92007–11, 92013–14, 92018–27, 92029–30, 92033, 92037–40, 92046, 92049, 92051–52, 92054–58, 92064–65, 92067–69, 92071–72, 92074–75, 92078–79, 92081–85, 92091–93, 92096, 92101–24, 92126–32, 92134–40, 92142–43, 92145, 92147, 92149–50, 92152–55, 92158–61, 92163–79, 92182, 92186–87, 92190–93, 92195–99. Ventura County: 90265, 91304, 91307, 91311, 91319–20, 91358–62, 91377, 93001–07, 93009–12, 93015–16, 93020–22, 93030–36, 93040–44, 93060–66, 93094, 93099, 93252.

Who is eligible to join Kaiser Permanente Senior Advantage (HMO)?

You can join Kaiser Permanente Senior Advantage (HMO) if you are enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in Kaiser Permanente Senior Advantage (HMO) unless they are members of our organization and have been since their dialysis began.

Can I choose my doctors?

Kaiser Permanente Senior Advantage (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time.

You can ask for a current provider directory. For an updated list, visit us at kp.org/medicare. Our customer service number is listed at the end of this introduction.

What happens if I go to a doctor who’s not in your network?

If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the plan nor the Original Medicare Plan will pay for these services except in limited situations (for example, emergency care).

Where can I get my prescriptions if I join this plan?

Kaiser Permanente Senior Advantage (HMO) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at http://www.kp.org/seniorrx. Our customer service number is listed at the end of this introduction.

What if my doctor prescribes less than a month’s supply?

In consultation with your doctor or pharmacist, you may receive less than a month’s supply of

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of certain brand [and generic] drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate.

The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable

percentage of the drug cost. If you are responsible for a copay for the drug, a “daily cost-sharing rate” will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month’s supply than you otherwise would have paid. Contact your plan if you have questions about cost-sharing when less than a one-month supply is dispensed.

Does my plan cover Medicare Part B or Part D drugs?

Kaiser Permanente Senior Advantage (HMO) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs.

What is a prescription drug formulary?

Kaiser Permanente Senior Advantage (HMO) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our

complete formulary on our Web site at http://www.kp.org/seniorrx.

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

How can I get extra help with my prescription drug plan costs or get extra help

with other Medicare costs?

You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call:

* 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048,

24 hours a day/7 days a week; and see http://www.medicare.gov “Programs for People with Limited Income and Resources” in the publication Medicare & You.

* The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or

* Your State Medicaid Office.

What are my protections in this plan?

Your employer or trust fund determines the benefits it will offer to its Medicare-eligible beneficiaries as well as eligibility requirements and share of cost (if any). As long as you meet your employer or trust fund's eligibility requirements and your employer or trust fund continues to offer Kaiser

Permanente Senior Advantage (HMO), you may remain a Senior Advantage member through your employer or trust fund, as long as Kaiser Permanente offers Medicare coverage. Benefits, eligibility requirements, and share of cost (if any) are generally communicated during your annual open enrollment period. If your employer or trust fund decides to terminate its coverage through Kaiser Permanente Senior Advantage (HMO), you may be eligible to join the Individual Kaiser Permanente Senior Advantage Plan, or you can remain with Original Medicare.

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I-5

All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of Kaiser Permanente Senior Advantage (HMO), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

As a member of Kaiser Permanente Senior Advantage (HMO), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must

provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Kaiser Permanente Senior Advantage (HMO) for more details.

What types of drugs may be covered under Medicare Part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Kaiser Permanente Senior Advantage (HMO) for more details.

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-- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

-- Osteoporosis Drugs: Injectable osteoporosis drugs for some women.

-- Erythropoietin: By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

-- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. -- Injectable Drugs: Most injectable drugs administered incident to a physician’s service. -- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the

transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. -- Some Oral Cancer Drugs: If the same drug is available in injectable form.

-- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. -- Inhalation and Infusion Drugs administered through Durable Medical Equipment.

Where can I find information on plan ratings?

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you can find the Plan Ratings information by using the Find health & drug plans web tool on

medicare.gov to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below.

Please call Kaiser Permanente for more information about Kaiser Permanente Senior Advantage (HMO).

Visit us at kp.org/medicare or, call us:

Customer Service Hours:

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific

Current members should call toll-free (800) 443-0815 for questions related to the Medicare Advantage Program or the Medicare Part D Prescription Drug program. (TTY/TDD 711)

Prospective members should call toll-free (800) 777-1238 for questions related to the Medicare Advantage Program or the Medicare Part D Prescription Drug program. (TTY/TDD 711)

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Or, visit http://www.medicare.gov on the web.

This document may be available in other formats such as Braille, large print or other alternate formats.

This document may be available in a non-English language. For additional information, call customer service at the phone number listed above.

Este documento puede estar disponible en otros idiomas aparte del inglés. Si desea información adicional, llame a Servicio al Cliente al número de teléfono antes indicado.

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II-1

If you have any questions about this plan’s benefits or costs, please contact Kaiser Permanente for details.

Section II – Summary of Benefits

Benefit Original Medicare

IMPORTANT INFORMATION

1 - Premium and Other Important Information

In 2013 the monthly Part B Premium was $104.90 and may change for 2014 and the annual Part B deductible amount was $147 and may change for 2014.

If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more.

Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call

1-877-486-2048. You may also call Social Security at

1-800-772-1213. TTY users should call 1-800-325-0778.

2 - Doctor and Hospital Choice

(For more information,

see Emergency Care - #15 and Urgently Needed Care - #16.)

You may go to any doctor, specialist or hospital that accepts Medicare.

SUMMARY OF BENEFITS

INPATIENT CARE

3 - Inpatient Hospital Care

(includes Substance Abuse and Rehabilitation Services)

In 2013 the amounts for each benefit period were: Days 1 - 60: $1,184 deductible

Days 61 - 90: $296 per day

Days 91 - 150: $592 per lifetime reserve day These amounts may change for 2014.

Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.

Lifetime reserve days can only be used once.

A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

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II-2 Benefit Original Medicare

4 - Inpatient Mental Health Care In 2013 the amounts for each benefit period were: Days 1 - 60: $1,184 deductible

Days 61 - 90: $296 per day

Days 91 - 150: $592 per lifetime reserve day These amounts may change for 2014.

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

5 - Skilled Nursing Facility (SNF)

(in a Medicare-certified skilled nursing facility)

In 2013 the amounts for each benefit period after at least a 3-day Medicare-covered hospital stay were:

Days 1 - 20: $0 per day Days 21 - 100: $148 per day

These amounts may change for 2014. 100 days for each benefit period.

A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

6 - Home Health Care

(includes medically necessary intermittent skilled nursing care, home health aide

services, and rehabilitation services, etc.)

$0 copay.

7 - Hospice You pay part of the cost for outpatient drugs and inpatient respite care.

You must get care from a Medicare-certified hospice.

OUTPATIENT CARE

8 - Doctor Office Visits 20% coinsurance

9 - Chiropractic Services Supplemental routine care not covered

20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

10 - Podiatry Services Supplemental routine care not covered.

20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs.

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II-3 Benefit Original Medicare

11 - Outpatient Mental Health Care

20% coinsurance for most outpatient mental health services Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.

“Partial hospitalization program”

is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization.

12 - Outpatient Substance Abuse Care

20% coinsurance

13 - Outpatient Services 20% coinsurance for the doctor’s services

Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital

deductible.

20% coinsurance for ambulatory surgical center facility services

14 - Ambulance Services

(medically necessary ambulance services)

20% coinsurance

15 - Emergency Care

(You may go to any emergency room if you reasonably believe you need emergency care.)

20% coinsurance for the doctor’s services

Specified copayment for outpatient hospital facility emergency services.

Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don’t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same

condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances.

16 - Urgently Needed Care

(This is NOT emergency care, and in most cases, is out of the service area.)

20% coinsurance, or a set copay

If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed-care visit. NOT covered outside the U.S. except under limited circumstances.

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II-4 Benefit Original Medicare

17 - Outpatient Rehabilitation Services

(Occupational Therapy, Physical Therapy, Speech and Language Therapy)

20% coinsurance

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

OUTPATIENT MEDICAL SERVICES AND SUPPLIES

18 - Durable Medical Equipment

(includes wheelchairs, oxygen, etc.)

20% coinsurance

19 - Prosthetic Devices

(includes braces, artificial limbs and eyes, etc.)

20% coinsurance

20% coinsurance for Medicare-covered medical supplies related to prosthetics, splints, and other devices.

20 - Diabetes Programs and Supplies

20% coinsurance for diabetes self-management training 20% coinsurance for diabetes supplies

20% coinsurance for diabetic therapeutic shoes or inserts

21 - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

20% coinsurance for diagnostic tests and x-rays $0 copay for Medicare-covered lab services

Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol.

22 - Cardiac and Pulmonary Rehabilitation Services

20% coinsurance for Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services

20% coinsurance for Intensive Cardiac Rehabilitation services

PREVENTIVE SERVICES

23 - Preventive Services No coinsurance, copayment or deductible for the following: - Abdominal Aortic Aneurysm Screening

- Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.

- Cardiovascular Screening

- Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk.

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II-5 Benefit Original Medicare

- Diabetes Screening - Influenza Vaccine

- Hepatitis B Vaccine for people with Medicare who are at risk - HIV Screening. $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor’s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test.

Medicare covers this test once every 12 months or up to three times during a pregnancy.

- Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one

baseline mammogram for women between ages 35-39. - Medical Nutrition Therapy Services

Nutrition therapy is for people who have diabetes or kidney disease (but aren’t on dialysis or haven’t had a kidney

transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease

- Personalized Prevention Plan Services (Annual Wellness Visits)

- Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more

information.

- Prostate Cancer Screening

- Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50.

- Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four

face-to-face visits.

- Screening and behavioral counseling interventions in primary care to reduce alcohol misuse

- Screening for depression in adults

- Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs

- Intensive behavioral counseling for Cardiovascular Disease (bi-annual)

- Intensive behavioral therapy for obesity

- Welcome to Medicare Preventive Visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare

Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months.

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II-6 Benefit Original Medicare

24 - Kidney Disease and Conditions

20% coinsurance for renal dialysis

20% coinsurance for kidney disease education services

PRESCRIPTION DRUG BENEFITS

25 - Outpatient Prescription Drugs

Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

OUTPATIENT MEDICAL SERVICES AND SUPPLIES

26 - Dental Services Preventive dental services (such as cleaning) not covered.

27 - Hearing Services Supplemental routine hearing exams and hearing aids not covered.

20% coinsurance for diagnostic hearing exams.

28 - Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye, including an annual glaucoma screening for people at risk

Supplemental routine eye exams and eyeglasses (lenses and frames) not covered.

Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.

Wellness/Education and Other Supplemental Benefits & Services

Not covered.

Over-the-Counter Items Not covered.

Transportation

(Routine)

Not covered.

Acupuncture and Other Alternative Therapies

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III-1

Section III – More information about our plan

General exclusions (services our plan does not cover)

The following is a summary of excluded services and items, please refer to the Evidence of Coverage for complete details. These services and items are not covered by our plan unless they are covered by Original Medicare or they are described otherwise in the Evidence of Coverage:

Care in a licensed intermediate care facility.

Chiropractic services, except for manual manipulation of the spine to correct subluxation in accord with Medicare guidelines (or if covered under your group's plan).

Comfort, convenience, or luxury equipment or features.

Cosmetic surgery or procedures.

Custodial care unless it is provided with covered skilled nursing care and/or skilled rehabilitation services.

Dental care and dental X-rays.

Elective or voluntary enhancement procedures or services.

Experimental medical and surgical procedures, equipment, and medications.

Full-time nursing care in your home.

Hearing aids or exams to fit hearing aids, unless covered under your group's plan.

Homemaker services, including basic household assistance.

Meals delivered to your home.

Orthopedic shoes and supportive devices, unless the shoes are part of a leg brace or for persons with diabetic foot disease.

Physical examinations related to employment, insurance, licensing, court orders, parole, or probation.

Private duty nurses.

Reconstructive surgery that offers only a minimal improvement in appearance or is performed to alter or reshape normal structures of the body in order to improve appearance.

Routine foot care.

Services or items not approved by the Food and Drug Administration (FDA) that by law require FDA approval in order to be sold in the United States.

Services provided to veterans in Veterans Affairs (VA) facilities and services for conditions arising from military service that the law requires the Department of Veterans Affairs to provide.

Services (such as eye surgery or contact lenses to reshape the eye) for the purpose of correcting refractive defects of the eye such as myopia, hyperopia, or astigmatism.

Services that are not reasonable and not necessary according to the standards of the Original Medicare plan.

Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance).

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III-2

Travel and lodging expenses.

When a service is not covered, all services related to the noncovered service are excluded. This exclusion does not apply to services we would otherwise cover to treat complications of the noncovered service.

Case management

We have case management programs for members who have difficulty managing multiple chronic conditions. This program partners with nurses, social workers, and your primary care physician to address your needs. It provides education and teaches self-care skills to properly manage your chronic conditions. If you are interested in these programs, please ask your primary care physician for more information.

Privacy practices

Kaiser Permanente will protect the privacy of your protected health information in accord with applicable law. To learn more about our privacy practices, please refer to the Evidence of Coverage or kp.org to view our Notice of Privacy Practices.

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Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-443-0815. Someone who speaks English/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-443-0815. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务,帮助您解答关于健康或药物保险的任何疑 问。如果您需要此翻译服务,请致电 1-800-443-0815。我们的中文工作人员很乐意帮助 您。这是一项免费服务。 Chinese Cantonese:您對我們的健康或藥物保險可能存有疑問,為此我們提供免費的翻譯 服務。如需翻譯服務,請致電 1-800-443-0815。我們講中文的人員將樂意為您提供幫助。 這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang

mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-443-0815. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-443-0815. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi vềchương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-443-0815 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí.

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem

Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-443-0815. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역 서비스를제공하고있습니다. 통역서비스를이용하려면전화 1-800-443-0815번으로 문의해주십시오. 한국어를하는담당자가도와드릴것입니다. 이서비스는무료로 운영됩니다. Y0043_N009556 accepted 60134608 CA

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Russian:Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-443-0815. Вам окажет помощь сотрудник, который говорит по-pусски. Даннаяуслугабесплатная. Arabic:

.

ﺎﻧﻳﺩﻟ ﺔﻳﻭﺩﻷﺍ ﻝﻭﺩﺟ ﻭﺃ ﺔﺣﺻﻟﺎﺑ ﻕﻠﻌﺗﺗ ﺔﻠﺋﺳﺃ ﻱﺃ ﻥﻋ ﺔﺑﺎﺟﻺﻟ ﺔﻳﻧﺎﺟﻣﻟﺍ ﻱﺭﻭﻔﻟﺍ ﻡﺟﺭﺗﻣﻟﺍ ﺕﺎﻣﺩﺧ ﻡﺩﻘﻧ ﺎﻧﻧﺇ

ﺹﺧﺷ ﻡﻭﻘﻳﺳ .

5180-344-008-1

ﻰﻠﻋ ﺎﻧﺑ ﻝﺎﺻﺗﻻﺍ ﻯﻭﺳ ﻙﻳﻠﻋ ﺱﻳﻟ ،ﻱﺭﻭﻓ ﻡﺟﺭﺗﻣ ﻰﻠﻋ ﻝﻭﺻﺣﻠﻟ

ﺔﻳﺑﺭﻌﻟﺍ ﺙﺩﺣﺗﻳ ﺎﻣ ﺔﻳﻧﺎﺟﻣ ﺔﻣﺩﺧ ﻩﺫﻫ .ﻙﺗﺩﻋﺎﺳﻣﺑ

.

Hindi: हमारे स्वास्थ्य या दवा क� योजना के बारे म� आपके �कसी भी प्रश्न के जवाब देने के �लए हमारे पास मुफ्त दुभा�षया सेवाएँ उपलब्ध ह�. एक दुभा�षया प्राप्त करने के �लए, बस हम� 1-800-443-0815 पर फोन कर�. कोई व्यिक्त जो �हन्द� बोलता है आपक� मदद कर सकता है. यह एक मुफ्त सेवा है.

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-443-0815. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer

questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-443-0815. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-443-0815. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w

uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z

pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-443-0815. Ta

usługa jest bezpłatna.

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするため

に、無料の通訳サービスがありますございます。通訳をご用命になるには、

1-800-443-0815にお電話ください。日本語を話す人者が支援いたします。これは無料のサービス

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kp.org/medicare

Please recycle.

Kaiser Foundation Health Plan, Inc. 393 E. Walnut St.

Pasadena, CA 91188-8514 Member Service Contact Center

1-800-443-0815 (TTY 711) toll free

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KAISER PERMANENTE

Locations

It’s easy to find the care you need, when you need it. On average, our California

members have a Kaiser Permanente location within 8 miles of home. And since

most of our facilities offer many services under one roof, you can take care of a

variety of health care needs with every visit.

Convenient access

Many of our facilities offer same-day, after-hours, and weekend services. Some locations have specialty, after-hours, ob-gyn, and pediatric services available as well.

When you’re away from home

When you join Kaiser Permanente in California, you’re enrolled in either our Northern or Southern California Region. If you visit any other Kaiser Permanente region outside of where you live, you can receive care as a visiting member.

Find a location near you

Search by ZIP code or keyword at kp.org/facilities, or download our free Kaiser Permanente app for your smartphone or mobile device and use the location finder.

Locations

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San Mateo Northern California

The following information can help you find Kaiser Permanente and affiliated facilities in your community.

Fresno County

n Kaiser Permanente medical centers (hospital and medical offices)

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

86416

Maps not to scale

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n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

City Facility Address

Alameda ● Alameda Medical Offices 2417 Central Ave.

Antioch n Antioch Medical Center 4501 Sand Creek Road

● Delta Fair Medical Offices 3400 Delta Fair Blvd.

Bolinas Bolinas Family Practice 88 Mesa Road

Campbell ● Campbell Medical Offices 220 E. Hacienda Ave.

Clovis ● Clovis Medical Offices 2071 E. Herndon Ave.

Daly City ● Daly City Medical Offices 395 Hickey Blvd.

Davis ● Davis Medical Offices 1955 Cowell Blvd.

Elk Grove ● Elk Grove Medical Offices 9201 Big Horn Blvd.

● Elk Grove Promenade Medical Offices 10305 Promenade Pkwy.

Fairfield ● Fairfield Medical Offices 1550 Gateway Blvd.

Folsom ● Folsom Medical Offices 2155 Iron Point Road

Fremont n Fremont Medical Center 39400 Paseo Padre Pkwy.

Fresno n Fresno Medical Center 7300 N. Fresno St.

● First Street Medical Offices 4785 N. First St.

Gilroy ● Gilroy Medical Offices 7520 Arroyo Circle

Hayward n Hayward Medical Center 27400 Hesperian Blvd.

Lincoln ● Lincoln Medical Offices 1900 Dresden Drive

Livermore ● Livermore Medical Offices 3000 Las Positas Road

Manteca n Manteca Medical Center 1777 W. Yosemite Ave.

● Manteca Medical Offices 1721 W. Yosemite Ave.

Martinez ● Martinez Medical Offices 200 Muir Road

Mill Valley ● Mill Valley Medical Offices 750 Redwood Hwy.

Milpitas ● Milpitas Medical Offices 770 E. Calaveras Blvd.

Modesto n Modesto Medical Center 4601 Dale Road

● Bangs Avenue Medical Offices 4125 Bangs Ave.

● Dale Road Medical Offices 3800 Dale Road

● Modesto Medical Offices 4601 Dale Road

● Standiford Avenue Medical Offices 1320 Standiford Ave.

Cornerstone Family Practice Medical Group

1444 Florida Ave.

Family Health Care Medical Group 1320 Celeste Drive

86416

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n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

City Facility Address

Mountain View ● Mountain View Medical Offices 555 Castro St.

565 Castro St.

Napa ● Napa Medical Offices 3285 Claremont Way

1675 Permanente Way

Novato ● Novato Medical Offices 97 San Marin Drive

Oakhurst ● Oakhurst Medical Offices 40595 Westlake Drive

Oakland n Oakland Medical Center 280 W. MacArthur Blvd.

Patterson First Care Medical Center 101 N. Third St.

Petaluma ● Petaluma Medical Offices 3900 Lakeville Hwy.

Pinole ● Pinole Medical Offices 1301 Pinole Valley Road

Pleasanton ● Pleasanton Medical Offices 7601 Stoneridge Drive

Point Reyes Station Point Reyes Medical Clinic 3 Sixth St.

West Marin Medical Center 11150 State Route 1

Rancho Cordova ● Rancho Cordova Medical Offices 10725 International Drive

Redwood City n Redwood City Medical Center 1150 Veterans Blvd.

Richmond n Richmond Medical Center 901 Nevin Ave.

Rohnert Park ● Rohnert Park Medical Offices 5900 State Farm Drive

Roseville n Roseville Medical Center 1600 Eureka Road

● Roseville Medical Offices – Riverside 1001 Riverside Ave.

Sacramento n Sacramento Medical Center 2025 Morse Ave.

n South Sacramento Medical Center 6600 Bruceville Road

● Fair Oaks Boulevard Medical Offices 2345 Fair Oaks Blvd.

● Point West Medical Offices 1650 Response Road

San Bruno ● Bayhill Medical Offices 801 Traeger Ave.

851 Traeger Ave.

● San Bruno Medical Offices 901 El Camino Real

● Sneath Lane Medical Offices 1001 Sneath Lane

1011 Sneath Lane

San Francisco n San Francisco Medical Center 2425 Geary Blvd.

San Jose n San Jose Medical Center 250 Hospital Pkwy.

San Leandro n San Leandro Medical Center

(Scheduled to open spring 2014.)

2500 Merced St.

San Mateo ● San Mateo Medical Offices 1000 Franklin Pkwy.

San Rafael n San Rafael Medical Center 99 Montecillo Road

● Downtown San Rafael Medical

Offices – 3rd St.

1033 Third St.

86416 Locations Northern California

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n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

City Facility Address

San Ramon ● San Ramon Medical Offices

(Scheduled to open fall 2013.)

2500 Merced St.

Santa Clara n Santa Clara Medical Center 700 Lawrence Expwy.

● Santa Clara Arques Medical Offices 1263 Arques Ave.

● Santa Clara Medical Offices 710 Lawrence Expwy.

Santa Rosa n Santa Rosa Medical Center 401 Bicentennial Way

● Santa Rosa Richard Stein

Medical Offices

3925 Old Redwood Hwy. 3975 Old Redwood Hwy.

Selma ● Selma Medical Offices 2651 Highland Ave.

South San Francisco n South San Francisco Medical Center 1200 El Camino Real

Stinson Beach Stinson Beach Medical Center 3419 State Route 1

Stockton ● Stockton Medical Offices 7373 West Lane

Dameron Hospital1 525 W. Acacia St.

Tracy ● Tracy Medical Offices 2185 W. Grant Line Road

Turlock Rodney Avilla, DO 2101 Geer Road

Jagmohan Bhinder, MD 1860 Colorado Ave.

Maryam Esho, MD 1729 N. Olive Ave.

Nirbhai Hundal, MD 1516 Colorado Ave.

Puliadi Kumar, MD 1110 Delbon Ave.

Turlock Pediatric Medical Group 1100 Delbon Ave.

Union City ● Union City Medical Offices 3551 Whipple Road

3553 Whipple Road 3555 Whipple Road

Vacaville n Vacaville Medical Center 1 Quality Drive

Vallejo n Vallejo Medical Center 975 Sereno Drive

Walnut Creek n Walnut Creek Medical Center 1425 S. Main St.

● Park Shadelands Medical Offices 320 Lennon Lane

86416

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Santa Rosa Mountains San Jacinto Mountains San Bernardino National Forest San Bernardino National Forest Cleveland National Forest San Bernardino Mountains Cleveland National Forest Anza-Borrego Desert State Park Edwards Air Force Base

China Lake Naval Weapons Center

Tehachapi Mountains Sierra Nevada Mountains Mission Hills Southern California

The following information can help you find Kaiser Permanente and affiliated facilities in your community.

n Kaiser Permanente medical centers (hospital and medical offices)

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices Kern County area

86416

Maps not to scale

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n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

City Facility Address

Aliso Viejo ● Aliso Viejo Medical Offices 24502 Pacific Park Drive

Anaheim n Orange County–Anaheim

Medical Center

3440 E. La Palma Ave.

● Anaheim Hills Medical Offices 5475 E. La Palma Ave.

● Anaheim Kraemer

Medical Offices

3460 E. La Palma Ave., Building 1 3430 E. La Palma Ave., Building 2

● Euclid Medical Offices 1188 N. Euclid St.

● Lakeview Medical Offices 411 N. Lakeview Ave.

Bakersfield ● Central Medical Offices 3733 San Dimas St.

● Chester Avenue Medical Offices 2531 Chester Ave.

● Coffee Road Medical Offices 4801 Coffee Road

● Discovery Plaza Medical Offices 1200 Discovery Drive

● East Hills Medical Offices 3700 Mall View Road

● Ming Medical Offices 8800 Ming Ave.

● Stockdale Medical Offices 3501 Stockdale Hwy.

San Joaquin Community Hospital –

Emergency services1

2615 Chester Ave.

Baldwin Park n Baldwin Park Medical Center 1011 Baldwin Park Blvd.

Bellflower ● Bellflower Medical Offices 9400 E. Rosecrans Ave.

● Rosecrans Medical Offices 9333 E. Rosecrans Ave.

Bonita ● Bonita Medical Offices 3955 Bonita Road

Brea ● Brea Medical Offices 1900 E. Lambert Road

Camarillo ● Camarillo 2620 Las Posas Road

Medical Offices

2620 E. Las Posas Road

Carlsbad ● Carlsbad Medical Offices 6860 Avenida Encinas

Carson ● Carson Medical Offices

(Scheduled to open summer 2013.)

18600 South Figuero St.

Chino ● Chino Medical Offices 11911 Central Ave.

City of Industry ● Crossroads Medical Offices 12801 Crossroads Pkwy. S.

Claremont ● Indian Hill Medical Offices 250 W. San Jose St.

Colton ● Colton Medical Offices 789 E. Cooley Drive

Corona ● Corona Medical Offices 2055 Kellogg Ave.

Cudahy ● Cudahy Medical Offices 7825 Atlantic Ave.

Culver City ● Playa Vista Medical Offices 5620 Mesmer Ave.

Diamond Bar ● Diamond Bar Medical Offices 1336 Bridgegate Drive

Downey n Downey Medical Center 9333 E. Imperial Hwy.

● Garden Medical Offices 9353 E. Imperial Hwy.

● Orchard Medical Offices 9449 E. Imperial Hwy.

El Cajon ● Bostonia Medical Offices 1630 E. Main St.

● El Cajon Medical Offices 250 Travelodge Drive

86416

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n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

City Facility Address

Escondido ● Escondido Medical Offices 732 N. Broadway

Palomar Health Downtown Campus 555 E. Valley Pkwy.

Palomar Medical Center –

Emergency services1

2185 W. Citracado Pkwy.

Foothill Ranch ● Foothill Ranch Medical Offices 26882 Towne Centre Drive

Fontana n Fontana Medical Center 9961 Sierra Ave.

Garden Grove ● Garden Grove Medical Offices 12100 Euclid St.

Gardena ● Gardena Medical Offices 15446 S. Western Ave.

Glendale ● Glendale Orange Street

Medical Offices

501 N. Orange St.

Huntington Beach ● Huntington Beach Medical Offices 18081 Beach Blvd.

Harbor City n South Bay Medical Center 25825 S. Vermont Ave.

Huntington Beach ● Huntington Beach Medical Offices 18081 Beach Blvd.

Indio ● Kaiser Permanente Indio

Medical Offices

46-900 Monroe St. John F. Kennedy Memorial

Hospital – Emergency services1

47111 Monroe St.

Inglewood ● Inglewood Medical Offices 110 N. La Brea Ave.

Irvine n Orange County–Irvine Medical Center 6640 Alton Pkwy.

● Alton/Sand Canyon Medical Offices 6650 Alton Pkwy.

6670 Alton Pkwy.

● Barranca Medical Offices 6 Willard

Joshua Tree Hi-Desert Medical Center –

Emergency services1

6601 White Feather Road

La Mesa ● La Mesa Medical Offices 8080 Parkway Drive

● Rancho San Diego Medical Offices 3875 Avocado Blvd.

La Palma ● La Palma Medical Offices 5 Centerpointe Drive

Lancaster ● Lancaster Medical Offices 43112 N. 15th St. W.

● Women’s Health Office (Ob-Gyn) 44105 15th St. W.

Antelope Valley Hospital –

Emergency services1

1600 W. Avenue J

Long Beach ● Long Beach Medical Offices 3900 E. Pacific Coast Hwy.

Los Angeles n Los Angeles Medical Center 4867 W. Sunset Blvd.

n West Los Angeles Medical Center 6041 Cadillac Ave.

● Culver Marina Medical Offices 12001 W. Washington Blvd.

● East Los Angeles Medical Offices 5119 E. Pomona Blvd.

● South Los Angeles Medical Offices 1550 W. Manchester Ave.

Lynwood ● Lynwood Medical Offices 3830 Martin Luther King Jr. Blvd.

Mission Hills ● Mission Hills Medical Offices 11001 Sepulveda Blvd.

Mission Viejo ● Mission Viejo Medical Offices 23781 Maquina Ave.

86416 Locations Southern California

(32)

n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

City Facility Address

Montebello ● Montebello Medical Offices 1550 Town Center Drive

Moreno Valley ● Moreno Valley Medical Center –

Medical Office Building 2

27200 Iris Ave.

● Heacock Medical Offices 12815 Heacock St.

● Iris Medical Offices 27350 Iris Ave.

Murrieta Rancho Springs Medical Center 25500 Medical Center Drive

North Hollywood ● North Hollywood Medical Offices

(Scheduled to open summer 2013.)

5250 Lankershim Blvd.

Norwalk ● Norwalk Medical Offices 12501 E. Imperial Hwy.

Oceanside ● Oceanside Medical Offices 3609 Ocean Ranch Blvd.

Ontario n Ontario Medical Center 2295 S. Vineyard Ave.

Oxnard ● Oxnard 2103 East Gonzales

Road Medical Offices

2103 E. Gonzales Road

● Oxnard 2200 East Gonzales Road

Medical Offices

2200 E. Gonzales Road

Palm Desert ● Kaiser Permanente

Palm Desert Medical Offices

75-036 Gerald Ford Drive

Palm Springs ● Kaiser Permanente

Palm Springs Medical Offices

1100 N. Palm Canyon Drive Desert Regional Medical Center –

Emergency services1

1150 N. Indian Canyon Drive

Palmdale ● Palmdale Medical Offices 4502 E. Avenue S

Panorama City n Panorama City Medical Center 13651 Willard St.

Pasadena ● Pasadena Medical Offices 3280 E. Foothill Blvd.

Rancho Cucamonga ● Rancho Cucamonga Medical Offices 10850 Arrow Route

Redlands ● Redlands Medical Offices 1301 California St.

Riverside n Riverside Medical Center 10800 Magnolia Ave.

San Bernardino ● San Bernardino Medical Offices 1717 Date Place

San Diego n San Diego Medical Center/

Kaiser Foundation Hospital

4647 Zion Ave.

● Carmel Valley Medical Offices

(Scheduled to open spring 2013.)

3851 Shaw Ridge Road

● Clairemont Mesa Medical Offices 7060 Clairemont Mesa Blvd.

● Mission Bay Medical Offices 3033 Bunker Hill St.

● Otay Mesa Medical Offices 4650 Palm Ave.

4660 Palm Ave.

● Point Loma Medical Offices 3250 Fordham St.

3420 Kenyon St.

● Rancho Bernardo Medical Offices 17140 Bernardo Center Drive

● Vandever Medical Offices 4405 Vandever Ave.

San Dimas ● San Dimas Medical Offices 1255 W. Arrow Hwy.

86416

(33)

City Facility Address

San Juan Capistrano ● San Juan Capistrano Medical Offices 30400 Camino Capistrano

San Marcos ● San Marcos Medical Offices 400 Craven Road

Santa Ana ● Harbor–MacArthur Medical Offices 3401 S. Harbor Blvd.

● Santa Ana Medical Offices 1900 E. Fourth St.

Santa Clarita ● Canyon Country Medical Offices 26415 Carl Boyer Drive

● Santa Clarita Medical Offices 27107 Tourney Road

Simi Valley ● Simi Valley Medical Offices 3900 Alamo St.

Temecula ● Temecula Medical Offices 27309 Madison Ave.

Thousand Oaks ● Thousand Oaks 365 East Hillcrest

Drive Medical Offices

365 E. Hillcrest Drive

● Thousand Oaks 145 Hodencamp

Road Medical Offices

145 Hodencamp Road

● Thousand Oaks 322 East Thousand

Oaks Boulevard Medical Offices

322 E. Thousand Oaks Blvd.

Torrance ● Torrance Medical Offices 20790 Madrona Ave.

Tustin ● Tustin Ranch Medical Offices

(Scheduled to open early 2014.)

2521 Michelle Drive

Upland ● Upland Medical Offices 1183 E. Foothill Blvd.

Ventura ● Ventura 2601 East Main Street

Medical Offices

2601 E. Main St.

● Ventura 888 South Hill Road

Medical Offices

888 S. Hill Road

● Ventura 1000 South Hill Road

Medical Offices

1000 S. Hill Road Community Memorial Hospital

of San Buenaventura –

Emergency services1

147 N. Brent St.

Victorville ● High Desert/Victorville Medical Offices 14011 Park Ave.

Vista ● Vista Medical Offices 780 Shadowridge Drive

West Covina ● West Covina Medical Offices 1249 S. Sunset Ave.

Whittier ● Whittier Medical Offices 12470 Whittier Blvd.

Wildomar ● Wildomar Medical Offices 36450 Inland Valley Drive

Inland Valley Medical Center 36485 Inland Valley Drive

Woodland Hills n Woodland Hills Medical Center 5601 De Soto Ave.

● Erwin Street Medical Offices 21263 Erwin St.

Yorba Linda ● Yorba Linda Medical Offices 22550 Savi Ranch Pkwy.

n Kaiser Permanente medical centers (hospital and medical offices)

Locations are in bold.

● Kaiser Permanente medical offices

Affiliated plan hospitals

Affiliated medical offices

86416

Affiliated plan facilities provide selected inpatient and/or outpatient hospital and emergency services.

The information in this guide is current as of the date of publication (July 2013). If you have questions about the information in this guide, please contact our Member Service Call Center at 1-800-464-4000 (1-800-777-1370 for the hearing/speech impaired), weekdays from 7 a.m. to 7 p.m. and weekends from 7 a.m. to 3 p.m.

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