BENEFIT CHART

This Benefit Chart is a brief summary of coverage for eligible members. For more detailed information, contact Kaiser Permanenteís Information Center at (303) 338-3800 or your Groupís personnel office.

(These benefits and services are covered only when medically necessary and provided or authorized by a Medical Group Physician).			Prevention Plan 405
			YOU PAY
At Medical Offices	Diagnostic and Treatment Services	Doctor or nurse visit Allergy testing and treatment Short-term physical, occupational and speech therapy Therapeutic X-ray	$5 EACH VISIT
		Diagnostic laboratory and X-ray services	NO CHARGE
		Vision and hearing tests	$5 EACH VISIT
	Preventive Services	Well baby/well child visit Health maintenance visit. Immunization visit Breast screening exam and mammogram Pap smear and exam Colorectal cancer screening	NO CHARGE
In Designated Hospitals (No limit on covered days.)		Physician and surgeon services including operations, anesthesia and consultations Lab, X-ray and other diagnostic services Drugs. Blood, blood products and administration Special duty nursing when prescribed Short-term physical, occupational and speech therapy Dressings and casts	NO CHARGE
Maternity Care	Inpatient	Physician and hospital services	NO CHARGE
	Outpatient	Prenatal and postpartum visits	NO CHARGE
Emergency Services	In Area	Plan Facilities Covered 24 hours a day at Plan-designated facilities	$5 EACH VISIT
		Non-Plan Facilities There is a charge for Emergency Services received from non-Plan providers or facilities	$50 EACH VISIT WAIVED IF HOSPITALIZED
	Out of Area	Covered 24 hours a day *	$5 EACH VISIT
Mental Health	Inpatient	Up to 45 days of hospital care per calendar year reduced by 1 day for each 2 sessions of day/night care	DAYS 1-20 NO CHARGE DAYS 21-45/50%
	Outpatient	Individual visits	VISITS 1-10/$5 EACH VISITS 11 +/$25 EACH
		Group visits	$5 EACH VISIT
Substance Abuse Treatment	Inpatient	Medically indicated alcohol and drug detoxification	NO CHARGE
	Outpatient	Some groups may have purchased additional coverage	SEE ATTACHED DESCRIPTION
Extended Care in a Skilled Nursing Facility		For members who need skilled nursing care 24 hours a day Custodial care is not covered	NO CHARGE
In Your Home		Health services provided in your home and prescribed by a Medical Group Physician	NO CHARGE
Hospice Care		For terminally ill patients	NO CHARGE
Ambulance Service		Provided in the Service Area if other means of transportation would adversely affect your condition	NO CHARGE

^* Benefits and Supplemental Charges in other Kaiser Permanente Regions vary. You will receive the coverage most nearly comparable to your coverage in the Colorado Region except that organ transplants are provided only in accord with your coverage in Colorado.

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NAVIGATION

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Introduction | Benefit Changes | How to Use | Definitions | How Your Plan Works | Who Is Eligible | When Coverage Starts | Benefits And Services | Referrals and Restrictions on Choice of Providers | Emergency Services | Urgent Care | Health Plan's Appeals Procedure | Special Claims Procedures for Medicare Members | General Provisions | Binding Arbitration | Coordination Of currentbenefits | Medicare | What Is Not Covered | When Coverage Stops | Continuation Of Coverage | Customer Satisfaction Procedure | Service Information | Statement Of Financial Condition | Important Phone Numbers | Local Designated Hospitals | Supplemental Benefits | Benefit Chart

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Website for Kaiser of Colorado

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Denver Public Schools
Employee Benefits Department
900 Grant Street, Room 502
Denver, Colorado 80203
(303) 764-3371