SUPPLEMENTAL BENEFITS

$5.00 PRESCRIPTION DRUG BENEFIT

Prescribed covered drugs are provided at a maximum charge of $5.00 for each prescription (except for internally implanted

time-release drugs, drugs for treatment of involuntary infertility and drugs for hormonal treatment of prostate cancer),

not to exceed the amount prescribed, up to a 60-day supply. Each prescription refill is provided on the same basis as the

original prescription. If requested, refills will be mailed through Direct Rx, Kaiser Permanente's mail order prescription

service. Reorder envelopes are available at any Kaiser Permanente pharmacy and are included in every prescription order

mailed by Direct Rx. Refills will be mailed by First Class U.S. Mail or by UPS with no charge for postage or handling.

Direct Rx can be used 24 hours a day by calling 344-7986.

There is a minimal delivery charge for prescriptions sent by delivery service.

The following drugs are covered only when prescribed by (1) a Kaiser Permanente physician, (2) a physician to whom a

member has been referred by a Kaiser Permanente physician, or (3) a dentist; and obtained at a Kaiser Permanente

pharmacy:

1) Drugs for which a prescription is required by law. Kaiser Permanente pharmacies may substitute a chemical or generic

equivalent to a name brand drug unless prohibited by a physician. If a Member requests a name brand form of the

prescribed or authorized drug, the Member must pay any difference in price between the chemical or generic equivalent drug prescribed or authorized by the Physician and the requested brand, unless the Physician has requested and receive approval for the brand name due to medical necessity.

2) Insulin.

3) Niacin.

4) Compounded dermatological preparations.

5) Internally implanted time-release drugs are provided at a charge determined by multiplying the charge for a 30 day

supply of a drug by the expected number of months that it will be effective. Norplant, an internally implanted time-

release contraceptive, is provided at a charge of $200. No refund is given if the drug is removed.

6) Drugs for treatment of involuntary infertility are provided upon payment of 50% of member charges.

7) Drugs for Treatment of Prostate Cancer. LH-RH agonists (such as Lupron Depot injections) prescribed for hormonal

treatment of prostate cancer are provided with a copayment of 20% of Member charges, unless a Physician

determines no clinically equivalent alternative therapy exists.

Exclusions:

1) Prescription drugs that are necessary for services excluded under the Service Agreement.

2) Drugs not included in the Kaiser Permanente Drug Formulary, unless a non-formulary drug has been specifically

prescribed or authorized through the non-formulary process.

 

DURABLE MEDICAL EQUIPMENT AND ORTHOTIC
AND PROSTHETIC DEVICES
(DME 20% - OXYGEN 100%)

Coverage is limited to the standard item of durable medical equipment, orthotic device or prosthetic device that adequately

meets a member's medical needs. Convenience and luxury items and features are not covered.

Durable medical equipment, orthotic devices and prosthetic devices are provided upon payment of 20% of member charges

when prescribed by a Kaiser Permanente physician and obtained from a source designated by Kaiser Permanente. These

include:

1) Durable medical equipment is equipment that is appropriate for use in the home, necessary to serve a medical purpose

and able to withstand repeated use. It includes infant apnea monitors. When use is no longer needed by a member or

prescribed by a Kaiser Permanente physician, durable medical equipment that has been rented must be returned to

Kaiser Permanente or its designee. If the rented equipment is not returned, the member must pay Kaiser Permanente

or its designee the fair market price, established by Kaiser Permanente, for the equipment.

2) Orthotic devices (rigid or semi-rigid external devices other than casts) that replace the function of an inoperative or

malfunctioning body part or restrict motion in a diseased or injured part of the body.

3) Prosthetic devices (rigid or semi-rigid external devices) that replace all or part of a body organ or extremity.

4) Replacements or repairs unless necessitated by misuse or loss.

Oxygen and oxygen dispensing equipment for use in conjunction with durable medical equipment prescribed by a physician

is provided without charge.

Exclusions. The following are not covered:

1) Corrective shoes, orthotic devices for podiatric use and arch supports.

2) Dental prostheses, devices and appliances except for medically necessary treatment of cleft lip or cleft palate for

newborn members when prescribed by a Kaiser Permanente physician.

3) More than one orthotic or prosthetic device for the same part of the body, except for covered replacements.

4) More than one piece of durable medical equipment serving essentially the same function, except for covered

replacements.

5) Electric monitors of bodily functions.

6) Devices to perform medical testing of body fluid, excretions or substances.

7) Devices not medical in nature such as whirlpools, saunas and elevators.

8) Convenience or comfort items.

9) Disposable supplies.

These exclusions do not apply to durable medical equipment, orthotic devices or prosthetic devices which are covered by

Medicare, and are provided to Medicare members, Senior Advantage members and Part B members upon payment of 20% of Medicare-approved charges per item.

 

SUBSTANCE ABUSE REHABILITATION BENEFIT - A

The determination of the need for services of a specialized facility or program under this benefit and referral to such a

facility or program is made by or under the supervision of a Kaiser Permanente physician. Kaiser Permanente's payment

obligations for this benefit are conditioned upon the member completing the prescribed program.

INPATIENT SERVICES OF A SPECIALIZED FACILITY

During any 12-month period, beginning with the date services are provided under this benefit, Kaiser Permanente will pay

80% of the cost up to $7,000 for counseling and services for rehabilitation in a specialized inpatient alcoholism, drug abuse

or drug addiction treatment facility.

OUTPATIENT SERVICES OF A SPECIALIZED PROGRAM

During any 12-month period, beginning with the date services are provided under this benefit, Kaiser Permanente will pay

80% of the cost up to $1,300 for outpatient counseling and services for rehabilitation in a specialized outpatient alcoholism,

drug abuse or drug addiction treatment facility.

DETOXIFICATION

During any 12-month period in which a member is receiving services in a specialized treatment facility or program as

described above, Kaiser Permanente will pay up to 50% of the cost up to $500 for up to two detoxification's in a specialized

facility or program.

The exclusions and limitations of this Substance Abuse Rehabilitation Benefit are listed on page 15.

 

CHIROPRACTIC SERVICES - PLAN D

Coverage includes evaluation, laboratory services and X-rays required for chiropractic services, and treatment of

musculoskeletal disorders by participating chiropractors for $10 each visit. Up to 20 self-referred visits per calendar

year are covered when services are provided by participating chiropractors.

Exclusions:

Any treatment or services delivered by a participating chiropractor or his or her employee, determined not to be

chiropractically necessary by a participating chiropractor, or services in excess of the benefit maximum. Treatment

or services for pre-employment physicals. Hypnotherapy, behavior training, sleep therapy or weight loss programs.

Laboratory tests, or X-rays or other treatment classified as experimental or in the research stage that have not been

documented as chiropractically necessary or appropriate. Services not related to the examination and/or treatment

of the musculoskeletal system. Vocational rehabilitation services. Thermography. Air conditioners, air purifiers,

therapeutic mattresses, supplies, or any other similar devices and appliances. Transportation costs

including local ambulance charges. Prescription drugs, vitamins, minerals, nutritional supplements or other

similar-type products. Educational programs. non-medical self-care, or self-help training, and any or all diagnostic

testing related to these excluded services. MRI and/or other types of diagnostic radiology. Physical or massage therapy

that is not a part of the chiropractic treatment. Durable medical equipment

and/or supplies for use in the home.

---

NAVIGATION

---

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

---

Website for Kaiser of Colorado

---

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