PART ONE - KAISER PERMANENTE PLAN MEMBER HANDBOOK

Your member handbook is designed to help you understand what you need to do to obtain maximum benefits and to help control the cost of your health care. This handbook is your guide. Please read it carefully before you need to use any services.

A.

Your Plan Sponsor

UCAR has established a Plan through a contract with Kaiser Permanente. Through this Plan you are a member of the Kaiser Permanente Health Maintenance Organization (HMO)and have access to Health Services from Kaiser Permanente Physicians.

B.

Your Membership Identification Card

You have been given a Kaiser Permanente identification card that is yours alone. You will need this card when requesting services. If you are seeking care for a Covered Dependent, be sure you have his or her own membership card at the time of service.

Please carry your card with you at all times. It contains important information and identifies you as a UCAR employee participating in the Kaiser Permanente HMO Plan.

A.

Your Kaiser Permanente Physician

When you enrolled in this Plan, Kaiser Permanente automatically assigned you to a medical office in your area based on your residential zip code. If for any reason, you want to transter to a different location, you may do so by calling Kaiser Permanente Customer Service at (303) 338-3800.

You can choose a Primary Care Physician (PCP) or transfer to a different PCP, by calling Customer Service at (303) 338-3800. Other members of your family covered by this Plan must also seek care through a Kaiser Permanente Physician; however, you may each have different Kaiser Permanente Physicians. A successful doctor-patient relationship is important. The PCP you selected will direct your medical care, order x-rays and laboratory tests, prescribe medications and physical therapy, refer you to a specialist when necessary, and arrange hospitalization when medically required.

B.

Referrals to Specialists

If you need specialty care, your Personal Primary Care Physician will refer you to a Kaiser Permanente specialist or to an appropriate Physician not associated with Kaiser Permanente. Your unique needs will determine the specialist to whom you are referred.

All specialty care must be referred by your Personal Primary Care Physician. If you feel you need to see a specialist, discuss this with your Personal Primary Care Physician.

C.

Inpatient Hospital Care

If you need inpatient Hospital care, your Physician will authorize the services that are most appropriate for your condition and circumstances. You may be admitted to a Kaiser Permanente facility or Skilled Nursing Facility, or you may receive care at home through a home health care agency. To be covered, all inpatient Hospital care must be referred and authorized by your Physician.

A.

To Make Appointments

Your Personal Primary Care Physician is your personal Kaiser Permanente Plan Doctor. He or she will care for the majority of your health care needs. Your Kaiser Permanente Physician will also refer you for any specialty care, inpatient care or other services which are Medically Necessary. Except in Medically Necessary Emergencies, this Plan will not pay expenses for any care or service not performed, directed or referred by your Physician.

B.

Routine Primary Care Appointments

Call the Kaiser Permanente "Call Center", 24 hours a day, seven days a week, as listed in the "Member Services Guide and Telephone Directory," for future and same day appointments. You will need to give your Kaiser Permanente Plan Identification number when you make your appointment.

If you are unable to keep your appointment, phone the Call Center as soon as you can so that another patient may use the time. The appointment clerk at the Call Center will help you schedule another appointment.

C.

Same Day Appointments

If you feel your medical problem is so urgent that you must see or talk to your Physician that same day, call the Kaiser Permanente Call Center to speak to an advice nurse or make a same-day appointment.

1.

You will be given instructions to follow at home or you may be scheduled for a same day appointment.

2.

If your problem requires emergency room treatment, you will be directed to the appropriate medical office or emergency room.

3.

If you need urgent care after office hours, call the Call Center Advice lines, 24 hours a day, 7 days a week.

4.

You are responsible for a Copayment for outpatient medical office or Emergency room treatment.

D.

Medical Emergencies

Any illness or injury can be frightening. However, not all conditions are Medically Necessary Emergencies. Your Plan covers emergency room expenses for Medically Necessary Emergencies. If you are out of the Kaiser Permanente service area, obtain the care you need and file your claim with Kaiser Permanente within 180 days. If you are hospitalized notify Kaiser Permanente within 48 hours of commencement of emergency treatment. Refer to SECTION 4 - EMERGENCY SERVICES AND PROCEDURES for additional information. File your claim within 180 days of receiving care.

E.

Mental Health/Chemical Dependency Services

Mental Health and/or Chemical Dependency Services do not require a referral or authorization from your Physician. You may arrange for these services within the Kaiser Permanente facility on your own.

F.

Appointments With Specialists

All specialty care performed by non-Kaiser Permanente Physicians must be authorized and referred in advance by your Kaiser Permanente Physician.

After your Physician has authorized a referral for you to see a specialist or a non-Kaiser Permanente physician, the Business Office/Referral Center will assist you in making an appointment. Your Physician will give you a referral form to take with you to your appointment. All referral forms must be processed through the Referral Center.

Each referral authorization specifies the service and number of visits authorized. Do not make appointments for services or visits other than those authorized. If you feel you need additional care, please discuss this with your Primary Physician.

G.

To Arrange for Hospital Care

To be covered by your Plan, all non-emergency inpatient Hospital care must be authorized by your Physician.

H.

To Access Other Services

To be covered by your Plan, all medical services and supplies must be authorized by your Physician.

I.

Prescription Drugs

In order to have your prescriptions filled for the Copayment amount, you must use a Kaiser Permanente pharmacy.

As a member of Kaiser Permanente, you have the right . . .

To receive considerate and respectful health care, regardless of your nationality, race, creed, color, age, economic status, sex or lifestyle;

To obtain complete and current information about your illness or injury, your treatment, and the names of those responsible for your care;

To be given all of the information you need to give informed consent before the start of each procedure or treatment (legally requiring an informed consent). This information will include an explanation of procedures and any risks involved;

To expect Kaiser Permanente personnel to make a reasonable response to your requests;

To be given a reasonable estimate of the required amount of Copayment (if any) for your care, refer to the Copayment Schedule in SECTION 4 PART TWO - PLAN PROVISIONS, Copayment Schedule;

To be advised if your Plan does not cover expenses for a particular treatment being considered; and

To receive prompt treatment in an Emergency situation.

As a member of the Kaiser Permanente Plan, you have the responsibility . . .

To cooperate in full with the people caring for you;

To respect the rights of other patients and/or members;

To understand your health problems to your personal satisfaction. If you do not understand your illness, injury or treatment, talk with your Kaiser Permanente physician. Understanding your health problems is important to the success of treatment.

To be honest and direct with the people caring for you. Tell them exactly how you feel about what is happening to you;

To notify your Kaiser Permanente Physician about any unexpected changes in your health;

To understand Kaiser Permanente Plan procedures and referral system, and to use the Personal Primary Care Physician system appropriately;

To notify Kaiser Permanente about any change in membership information; and

To verify that the required approval for services has been granted.

A.

Copayments

You may need to pay a Supplemental Charge or Copayment when you use a specific health care service. For instance, you must pay a Copayment when you visit your Personal Primary Care Physician.

Copayments are to be paid directly to those providing services at the time of service. If you do not pay the Supplemental charge at the time you receive the service, you will be billed an additional $10.00 to cover the cost of sending a bill. For specific Copayment requirements refer to SECTION 4 PART TWO - PLAN PROVISIONS, Copayment Schedule.

B.

Lifetime Maximum

There is no Lifetime Maximum of benefits which may be payable while covered under this Plan.

C.

If You Should Receive a Bill

Kaiser Permanente eliminates nearly all of the paperwork involved in your health care. However, if you receive a bill for medical services performed by a non-Plan physician, you must file a claim to be reviewed by the Membership Claims Department within 180 days of receiving emergency care.

You are responsible for seeing that the following parties are notified:

Kaiser Permanente and UCAR, if there is a change in your membership information, or when you have a new address, phone number or name change;

Kaiser Permanente, if you want to transfer to a different Personal Primary Care Physician;

UCAR, if you need to add or delete a family member from your Plan Coverage. A birth, adoption, graduation, marriage, divorce or death may change the number of your Eligible Dependents; and

Kaiser Permanente and UCAR, if you move outside of a Kaiser Permanente Service Area. Your benefits could be severely limited and you may wish to transfer to a more suitable medical plan.

Kaiser Permanente works with you as a partner in your health care. By sharing your questions and thoughts, Kaiser Permanente can improve service for you and other members.

If you have questions about your benefits, claims, Kaiser Permanente procedures or the Physicians, please contact your local Kaiser Permanente's Information Center from 8:30 a.m.-5:00 p.m. Monday through Friday.

Kaiser Permanente is committed to providing you with quality, cost-efficient care and service. If you have a question or comment regarding your Health Services or claims, please let Kaiser Permanente know. Call a Customer Service representative at the Information Center to make sure problems are resolved promptly and fairly. Members are encouraged to speak with Medical Department Nursing Supervisors when they are dissatisfied with any aspect of their medical care.

Medical Emergencies can be frightening. Please become familiar with Kaiser Permanente Emergency Services and Procedures before you experience a medical Emergency.

Your Plan covers Emergency room treatment for Medically Necessary Emergencies only.

Any illness or injury is alarming. However, not all conditions are Medically Necessary Emergencies. A Medically Necessary Emergency has three requirements:

The condition must begin suddenly or unexpectedly and require immediate medical or surgical care.

You must seek care as soon as possible after the condition begins; and

Prompt treatment must be necessary to avoid serious bodily injury or death.

Medically Necessary Emergencies include, but are not limited to, conditions such as heart attacks, severe chest pain, strokes, severe bleeding, poisoning, major burns, loss of consciousness, serious breathing difficulties, spinal injuries and shock.

Children's ear aches, cuts, fevers and sore throats are alarming, but these problems are usually NOT Medically Necessary Emergencies. Emergency room treatment for these problems will NOT be covered by the Plan unless specifically authorized by your Physician.

A.

Emergencies Within the Service Area

1.

If you need an ambulance for immediate treatment, call 911. When you call the emergency number, Kaiser Permanente's medical staff will evaluate your emergency, order an ambulance, ask you to report directly to one of Kaiser Permanente's Medical Offices, or to the emergency room of a designated hospital. If it is medically necessary, an ambulance will be ordered for you.

2.

There are situations when it may be necessary for you to seek emergency care from a non-Plan physician or hospital. If the patient's condition is so critical that you do not have time to go to one of the Kaiser Permanente Medical Offices, or for reasons beyond your control, go directly to the nearest Medical Emergency facility. In the case of a life- or limb-threatening emergency, you may call 911. File a claim form within 180 days of receiving care.

3.

Within 48 hours after emergency hospital care is commenced, notify Kaiser Permanente at (303) 861-3434 or as soon as possible after receiving treatment. For individuals outside of Colorado, call (303) 338-3800 to obtain the phone number in your area to contact Kaiser Permanente.

4.

Follow-up care for Emergency treatment is covered only if performed by your Kaiser Permanente Physician.

5.

If you receive emergency services from non-Plan physicians or facilities within the service area, you will be charged $100.00. If you are subsequently hospitalized, the charges will be waived.

B.

Emergencies Outside the Service Area

1.

Go to the nearest medical facility equipped to treat your Emergency.

2.

Within 48 hours after inpatient hospital care is commenced, notify Kaiser Permanente's 24-hour emergency line. For their outpatient care phone the Information Center for a claim form. File your claim within 180 days of receiving care.

3.

Kaiser Permanente will pay reasonable charges for care. You are responsible for a Copayment for Emergency room or Special Care treatment, unless you are admitted directly into the Hospital.

4.

Your Plan does not pay for medical services received outside a Kaiser Permanente Service Area if you could reasonably have anticipated the need for these services. For instance, normal term childbirth outside the Service Area is not covered. Complications of pregnancy or premature deliveries are covered. Deliveries within 30 days of expected due date are not considered premature.

5.

Follow-up care for any Emergency treatment should be performed by your Kaiser Permanente Physician. There is a $500 limit for out of state follow-up care.

Medically Necessary ambulance service is covered only in an Emergency, or when authorized in advance by calling your Physician or Kaiser Permanente's 24 hour emergency line.

Medically Necessary ambulance service is covered only in an Emergency, or when authorized in advance by calling your Physician of Kaiser Permanante's 24 hour emergency line.

PART TWO - PLAN PROVISIONS

A.

Copayment Schedule (not inclusive)

Members who elect Lupron Depot injections rather than surgery to treat prostate cancer will be charged a 20% copayment per injection.

B.

Description of Benefits

The following are covered when Medically Necessary:

Physician Services

The following services will be provided to Covered Persons when the services are provided or referred by the Covered Person's Personal Primary Care Physician, unless alternative arrangements have been authorized in advance by Kaiser Permanente, or in the event of an Emergency.

1.

Services and supplies provided in a Physician's office, including diagnostic treatment and preventive medical care such as x-rays, electrocardiograms, electroencephalograms, and other clinical laboratory tests, well-baby care, physical examinations, application and removal of casts and dressings, immunizations, and Medically Necessary therapeutic injections.

2.

Eye exams provided by the Kaiser Permanente Physician or Kaiser Permanente Eye Care department optometrist or ophthalmologist.

3.

Physician surgical services and other medical care, including anesthesia, consultation with and treatment by Kaiser Permanente specialists, and services by surgical assistants only when authorized in advance by Kaiser Permanente, when provided in a Kaiser Permanente Physician's office.

4.

Allergy testing, testing materials and treatment services and materials.

5.

Dermatology services.

6.

Short-term physical, occupational and speech therapy. -- up to two months or 20 visits per therapy.

Copayment Charge for Physician Services: $10 per visit.

7.

Therapeutic x-ray

Copayment: $20 per visit.

8.

MRI, CT, RET, and nuclear medicine scans

Copayment: $100 per procedure.

Hospital and Related Services

The following services will be provided to Covered Persons when provided or referred by the Kaiser Permanente Physician:

Inpatient Services

When prescribed, the following hospital services are provided:

room and board;

general nursing care;

obstetrical care;

services and supplies;

use of operating room;

private room if medically necessary;

intensive care and related hospital service;

special diet;

special duty nursing;

medications (i.e., prescribed medications, injectables, radioactive materials used for therapeutic purposes, allergy test materials and all treatment materials);

medical supplies;

X-rays and laboratory services are provided (i.e., all prescribed x-ray and laboratory tests, services and materials, including diagnostic and therapeutic x-rays and isotopes, electrocardiograms, electroencephalograms);

physical therapy, occupational therapy and speech therapy

Up to two months in a multi-disciplinary rehabilitation program when prescribed by a Physician.

Copayment Charge for Inpatient Services: $250.00

Blood, blood products and the administration of blood are provided without charge. Replacement to a blood bank is not necessary.

Outpatient Services

Outpatient services are covered at either a Kaiser Permanente Medical Office or a designated emergency department and when provided or referred by the Kaiser Permanente Physician.

Copayment Charge for Outpatient Services: $50 per visit.

In the event of an Emergency, Emergency Health Services provided at or by non-Kaiser Permanente facilities or providers are covered subject to the terms of this handbook, and when Kaiser Permanente later determines these Emergency Health Services to be Medically Necessary.

1.

Emergency Services

a.

Services for stabilization or initiation of treatment of Emergency conditions, performed on an outpatient basis in a Kaiser Permanente medical office or a designated emergency department.

Copayment Charge: $100 per outpatient visit.

b.

Services for stabilization or initiation of treatment of Emergency conditions performed on an outpatient basis in a non-Kaiser Permanente Medical Office or by a care provider other than a Kaiser Permanente provider.

Copayment charge: $100 per visit. Call Kaiser Permanente's Claims Department to notify of emergency services.

c.

Outpatient Prescription Drugs obtained at a Kaiser Permanente medical office or a designated emergency department in conjunction with Emergency services.

Copayment Charge: $10.00 per Prescription Order, or the actual cost of the Prescription, whichever is less.

2.

Non-Emergency Services

a.

Surgical services, supplies and other medical care including anesthesia and services performed by surgical assistants are covered only when authorized in advance by Kaiser Permanente, for pre-scheduled outpatient surgery provided at a Kaiser Permanente Medical Office or a designated emergency department.

Copayment Charge: $100 registration fee per outpatient surgery.

b.

Pre-scheduled diagnostic and therapeutic services, including x-rays, radiation therapy, and laboratory tests and services provided at a Kaiser Permanente Medical Office or a designated emergency department.

Copayment Charge: $10 per visit.

Maternity Services

Maternity and obstetrical care mean pre-natal and post-partum care during pregnancy, childbirth, early termination of pregnancy or any associated complications.

This Plan covers hospital benefits relating to childbirth or care for a newborn child for a minimum of 48 hours following a normal vaginal delivery, or 96 hours following a caesarean section, unless a longer hospital stay is medically necessary and approved by the Plan.

1.

Services, equipment and supplies provided on an in-patient or outpatient basis for obstetrical care of the mother before and during delivery and during the post-partum period, including: physician services, operations and special procedures such as caesarean sections, Hospital services, use of the delivery room, x-ray and laboratory, injectable substances, and anesthesia.

Normal, full-term deliveries outside the Kaiser Permanente Service Area or home delivery, are not covered.

Copayment Charge: $10 per outpatient visit. Inpatient services are treated the same as under Hospital and Related Services in this Section.

2.

Family planning counseling, including abortion counseling and information on birth control is provided. Contraceptive devices are provided at reasonable charge. Contraceptive drugs are provided in accord with the Prescription Drug section outlined in this Section.

Copayment Charge: $10 per visit.

3.

Exclusions: The following services are not covered:

a.

The cost of donor semen and donor eggs.

b.

Services, other than artificial insemination, related to conception by artificial means, including, but not limited to, in vitro fertilization and ovum transplants.

c.

Services to reverse voluntary, surgically induced infertility.

d.

Gamete intrafallopian transfer and zygote intrafallopian transfer.

Mental Health Services

Subject to the exclusions mentioned in this Section, medical treatment, including counseling is provided in Hospitals and medical offices in accordance with the Kaiser Permanente Plan.

The following services are covered only when provided by a Kaiser Permanente Physician or Mental Health professional. Members self-refer to this department. Resulting Mental Health Services are covered only when provided through the Mental Health Provider.

1.

Inpatient Services

The Plan allows up to 45 days of inpatient days per calendar year. These Services include the services of Physicians and mental health professionals as performed, prescribed or directed by the Kaiser Permanente Physician, including individual therapy, group therapy, occupational therapy, shock therapy, drug therapy and psychiatric nursing care.

If, in the professional judgment of the Kaiser Permanente Physician, a Covered Person would benefit from day care or night care services, up to 40 sessions of prescribed care, and any additional sessions of day care or night care paid for in whole or in part under Medicare, are provided without charge each calendar year. Thereafter, up to an additional 50 sessions of prescribed care are provided at one-half non-member rates each calendar year. The number of covered sessions is reduced by two sessions for each day of hospitalization received by the Covered Person as described in the paragraph above.

Copayment Charge: $250.00

2.

Outpatient Mental Health Services

The Plan provides 20 outpatient visits per Calendar Year. These Services include diagnosic evaluation, individual therapy, group therapy and psychiatrically oriented child and teenage guidance counseling.

Copayment Charge: Office visit copay with a limit of 20 viists per year; two group therapy sessions equals one individual session

3.

Psychological Testing

If, in the professional judgment of the Kaiser Permanente physician, psychological testing is required as part of diagnostic evaluation, prescribed tests are provided.

Copayment Charge: No Charge

4.

Exclusions: The following services are not covered:

a.

Court-ordered testing and testing for ability, aptitude, intelligence or interest.

b.

Services for use in court proceedings as well as evaluations for purposes other than mental health treatment, such as child custody evaluations or disability evaluations, unless a physician determines such evaluation to be medically necessary.

c.

Services provided or arranged by criminal justice institutions for members confined therein are not covered, unless care is provided as a covered emergency service.

d.

Special education, counseling, therapy or care for learning deficiencies or behavioral problems, whether or not associated with a manifest mental disorder, retardation or other disturbance.

e.

Organic brain syndromes.

f.

Psychiatric therapy on court order or as a condition of parole or probation, unless a Kaiser Permanente physician determines such therapy to be necessary and appropriate.

Treatment for Alcoholism, Drug Abuse and Drug Addiction

Members may self-refer to Chemical Dependency Treatment Service Department. Subject to the exclusions mentioned below, medical treatment, including medical detoxification, and counseling related to the detoxification process for alcoholism and abuse or addiction to drugs is provided in Hospitals and medical offices in accordance with the Kaiser Permanente Plan. Detoxification refers to the removal of the toxic substance or substances from the system. Mental Health Services in conjunction with the treatment of alcoholism, drug abuse or drug addiction are provided in accordance with the Kaiser Mental Health benefits.

Charge: See below

Exclusions: The following services are not covered:

1.

Counseling for a patient who, or condition which, in the professional judgment of the Physician, would not be responsive to therapeutic management.

2.

Treatment for alcoholism, drug abuse and drug addiction on court order or as a condition of parole or probation, unless a Physician determines such treatment to be necessary and appropriate.

3.

Continuation in a course of treatment for a patient who is disruptive or physically abusive.

Drug and Alcohol Rehabilitation

The following services are covered only when referred by Kaiser Permanente.

The need for, and referral to, a specialized facility or program is made by a Kaiser Permanente personal assistance counsel or. Kaiser Permanente will pay its share of the treatment program only if the member completes the prescribed program.

1.

Inpatient Services of a Specialized Facility.

Services included are rehabilitation, counseling, and services in a specialized inpatient alcoholism, drug abuse or drug addiction treatment facility.

Copayment Charge: $250.00 Inpatient Hospital co-pay, up to 45 days, for each individual per 12-month period. This benefit applies only if you complete the prescribed treatment program.

2.

Outpatient Services of a Specialized Program.

Services included are rehabilitation, outpatient counseling and services in a specialized alcoholism, drug abuse or drug addiction treatment program.

Copayment Charge: Office visit co-pay with a limit of 20 visits per 12 month period.

3.

Detoxification in a Specialized Facility or Program.

Inpatient Hospital Co-payment Charge: $250 This benefit applies only if you complete the prescribed treatment program.

Outpatient Copayment Charge: Office visit co-pay with a limit of 20 visits per 12-month period. During any 12-month period in which a member is receiving services in a specialized treatment facility or program, Kaiser Permanente will pay for the admission at the hospital co-pay charge in a specialized facility or program for detoxification. This benefit applies only if you complete the prescribed treatment program.

4.

Exclusions: The following services are not covered:

a.

Counseling or services of a specialized facility for a patient or condition that, in the professional judgement of a Kaiser Permanente physician, would not respond to therapeutic management.

b.

Treatment for alcoholism, drug abuse and drug addiction on court order, or as a condition of parole or probation unless a Physician determines such treatment to be necessary and appropriate.

c.

Continuation in a course of treatment for a patient who is disruptive or physically abusive.

Prescription Drugs

Prescription Drugs are covered by the Plan when they have been prescribed under the direction of a Kaiser Permanente Physician or a Physician to whom a member has been referred by a Kaiser Permanente Physician or by a dentist and obtained at a Kaiser Permanente pharmacy.

1.

Covered medications include:

a.

The prescribed amount up to a 60 day supply, of drugs for which a prescription is required by law. Kaiser Permanente pharmacies may substitute a chemical or generic equivalent for a name brand medication unless prohibited by the Physician. If a member requests a name brand form of the prescribed or authorized medication, the member must pay any difference in price between the chemical or generic equivalent medication prescribed or authorized by the Physician and the requested brand.

b.

Compound dermatological preparations that must be prepared by a pharmacist in accordance with a Kaiser Permanente Physician's Prescription.

c.

Antacids.

d.

Insulin

e.

Contraceptive drugs.

f.

Internally implanted time-release medications are provided at a charge determined by multiplying the charge for a 30 days supply of a medication by the expected number of months that the medication will be effective. Norplant, an internally implanted time-release contraceptive, is provided at a charge of $200. No refund is given if the medication is removed before its life span has expired.

g.

Infertility medications are provided upon payment of 50% of member charges.

h.

Medications administered at no charge in medical offices, emergency departments or in a member's home are qualified to include only drugs and materials that require administration or observation by medical personnel during self-administration.

2.

Refills

Refills may be made by phone or mail order from your Kaiser Permanente pharmacy. Addressed return envelopes are available at the pharmacy counter.

To receive a refill by mail, send the refill order envelope to the Kaiser Permanente pharmacy. Refills will be mailed and there is no charge for postage or handling. refills may be ordered through the Kaiser Permanante Web Site at http://www.kponline.org.

3.

Exclusions: The following items are not covered:

a.

Drugs and medications needed for excluded services.

b.

Drugs and medications not included in the Kaiser Permanente drug formulary, unless a non-formulary drug has been specifically prescribed by the Physician.

c.

Contraceptive devices.

d.

Drugs and medications when used for cosmetic purposes.

Copayment Charge: $10 or cost of the prescription, whichever is less, for the prescribed amount up to a 60-day supply.

Immunizations

Immunizations that are medically indicated and consistent with accepted medical practice which were generally available in the Service Area on April 1 of the year immediately preceding the year in which this Plan became effective or was last renewed are provided without charge. All other immunizations medically indicated and consistent with medical practice are provided upon payment of one-half non-member rates.

Copayment Charge: No Charge

Miscellaneous Health Services

The following services are covered provided they are:

1.

Ordered, provided or arranged by, or under the direction of a Kaiser Permanente Physician, and

2.

Approved in writing in advance by Kaiser Permanente, and

3.

Obtained through a vendor or provider selected by Kaiser Permanente management.

a.

Home Health Services. Covered Home Health Services are provided. These services are limited to services of registered nurses and home health aides, short-term physical therapy, occupational therapy and speech therapy as prescribed or directed by a Kaiser Permanente physician. These services will be delivered only to persons who are homebound.

Copayment Charge: No Charge

b.

Skilled Nursing Facility. Extended or post-hospital skilled level care services. Custodial care is not covered.

Copayment Charge: No Charge. Maximum 100 days per calendar year.

c.

Ambulance Services. Medically Necessary ambulance transportation is covered if ordered or approved by Kaiser Permanente.

Copayment Charge: 20% up to a maximum of $500 per trip

d.

Rehabilitation Services.

Inpatient: During hospitalization, prescribed physical, occupational and speech therapy are provided for conditions which are subject to improvement within two months.

Outpatient: Up to two months or 20 visits per condition of prescribed physical, occupational or speech therapy services that are Medically Necessary and performed at a Kaiser Permanente Medical Office, Skilled Nursing Facility or through a Kaiser Permanente Home Health Care agency are provided for conditions which are subject to significant improvement within two months.

In a Rehabilitation Facility: Up to two months in a multidisciplinary rehabilitation program when prescribed by a Physician.

Limitations

1.

Occupational therapy is limited to services to achieve and maintain improved self-care and other customary activities of daily living.

2.

Speech therapy is limited to treatment for speech impairments of specific organic origin.

Copayment Charge:

Inpatient - No Charge

Outpatient -$10.00 per visit

Exclusions: The following services are not covered:

1)

Long-term rehabilitation;

2)

Pulmonary rehabilitation.

e.

Treatment of port wines stains on the face and neck for members 18 and younger.

Copayment Charge: No charge for inpatient care. $10 per visit for outpatient care.

f.

Cardiac rehabilitation services.

g.

Hospice care. Terminally ill patients with a life expectancy of six months or less may elect hospice care for such illness instead of the traditional services provided under this Plan.

Copayment Charge: No Charge.

h.

Care for Temporomandibular Joint Dysfunction is not a covered benefit. However, payment of medical procedures to treat the condition may be covered if treatment is at the direction of a Kaiser Permanente Physician. Dental procedures are not covered, including dental braces or appliances.

i.

Hemodialysis. Medical and Hospital Services for hemodialysis for renal disease are provided subject to the terms and conditions of this Plan. Hemodialysis for chronic conditions is provided only in facilities approved for participation in the Medicare program. Kaiser Permanente Physicians determine when a condition is chronic or acute. Equipment, training and medical supplies required for home dialysis are provided at no charge.

Copayment Charge: $10 per visit

j.

Transplants. Subject to the terms and conditions of this Plan, Medical and Hospital services for covered transplants are provided in accord with this Plan. Kaiser Permanente will pay the reasonable medical and hospital expenses of (a) a donor or (b) an individual identified by the Kaiser Permanente Physician as a prospective donor, if those expenses are directly related to the transplant. Covered transplants are:

1)

kidney transplants

2)

heart transplants

3)

heart-lung transplants

4)

liver transplants

5)

lung transplants

6)

bone marrow transplants

7)

cornea transplants

8)

simultaneous kidney/pancreas transplants

9)

small bowel/small bowel and liver tranplants

Exclusions: The following services are not covered:

1)

Non-human and artificial organs and their implantation.

2)

Most autologous bone morrow transplants.

Copayment Charge:

Inpatient - $250

Outpatient - $10 per visit

k.

Eyewear - Optical. The services described below are provided when prescribed by Kaiser Permanente Physicians or optometrists, and obtained at a Kaiser Permanente optical dispensing department.

Member will receive $150 credit every 24 months to apply towards the purchase of lenses, frames, or contact lenses.

Copayment Charge: Office visit copay per visit for vision examination. Contact lens services are provided on a discounted fee-for-service basis.

l.

Orthotic and Prosthetic Devices. The services and benefits listed below are provided when prescribed by a Kaiser Permanente Physician. Coverage is limited to the standard device that adequately meets the medical needs of the member. Convenience and luxury items and features are not covered.

1)

Orthotic devices (braces) are rigid or semi-rigid external devices other than casts that are required to support or correct a defective form or function of an inoperative or malfunctioning body part, or to restrict motion in a diseased or injured part of the body. A 20% charge will be applied to all items covered by the basic benefits for orthopedic braces.

2)

Prosthetic devices are those rigid or semi-rigid external devices that are required to replace all or any part of a body organ or extremity. When prescribed by a Kaiser Permanente Physician and obtained from sources designated by Kaiser Permanente, orthotic devices and prosthetic devices, including replacements other than those caused by misuse or loss, are covered upon payment of 20% of member charges. Necessary repairs and adjustments other than those caused by misuse, are covered when approved by a Kaiser Permanente Physician and obtained from a source designated by Kaiser Permanente. This benefit includes prosthetic devices following a covered mastectomy and orthopedic braces.

Exclusions. The following services are not covered:

a)

Corrective shoes, orthotic devices for podiatric devices and arch supports.

b)

Dental prostheses, devices and appliances. Exception: medically necessary orthodontic treatment and medically necessary prosthodontic treatment of cleft lip or cleft palate for newborn members are covered when prescribed by a Physician, unless the member is covered for these services under a dental insurance policy or contract.

c)

More than one orthotic and prosthetic device for the same part of the body. Spare devices or alternate use devices are not provided.

d)

Replacement of lost prosthetic and orthotic devices.

e)

Repairs, adjustments or replacements necessitated by misuse.

These exclusions do not apply to orthotic devices and prosthetic devices covered by Medicare, and are provided to Medicare members, Medicare Plus members and Part B members upon payment of 20% of Medicare approved charges.

Copayment Charge: 20% of member charges

m.

Durable Medical Equipment. Durable medical equipment is equipment that is used in the home, able to withstand repeated use, medically necessary, not of use to a person in the absence of illness or injury, and approved for coverage under Medicare and infant apnea monitors.

Coverage is limited to the standard item of durable medical equipment that adequately meets the medical need of the member. Convenience and luxury items and features are not covered.

1)

When prescribed by a Kaiser Permanente Physician and obtained from sources designated by Kaiser Permanente on either a purchase or rental basis, durable medical equipment for use in the home, including repair and replacements other than those caused by misuse or loss, is provided upon payment of 20% of member charges. Oxygen for use in conjunction with durable medical equipment prescribed by a Physician is also provided without charge. Members who use oxygen at home will be charged a 20% copayment.

Copayment Charge: 20% of member charges up to $2,000 annually

2)

When use is no longer prescribed by a Kaiser Permanente Physician, such durable medical equipment must be returned to Kaiser Permanente or its designee, or the member must pay Kaiser Permanente or its designee the fair market price established by Kaiser Permanente for the equipment.

3)

Exclusions. The following items are notcovered:

a)

Electric monitors of bodily functions, except infant apnea monitors.

b)

Devices to perform medical testing of body fluids, excretions or substances.

c)

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

d)

Convenience or comfort items.

e)

Disposable supplies.

f)

Replacement of lost equipment.

g)

Repair, adjustments or replacements necessitated by misuse.

h)

More than one piece of durable medical equipment serving essentially the same function. Spare equipment or alternate use equipment is not provided.

These exclusions do not apply to durable medical equipment for use in the member's home and covered by Medicare, and are provided to Medicare members, Medicare Plus members and Part B members upon payment of 20% of Medicare approved charges.

C.

Exclusions

D.

Limitations

Kaiser Permanente has no responsibility under the following circumstances:

1.

When delay or failure to perform services is due to major disaster or epidemic affecting Kaiser Permanente facilities or personnel.

2.

When unusual circumstances, such as complete or partial destruction of facilities, war, riot, labor disputes not involving Kaiser Permanente, disability of a significant number of personnel, or similar events result in a delay in providing services or inability to provide services. However, Kaiser Permanente personnel will use their best efforts to provide services and other benefits.

In cases of labor disputes involving Kaiser Permanente, Kaiser Permanente may defer the provision of non-emergency care until after resolution of the labor dispute.

3.

When a member has refused recommended treatment for personal reasons, and Kaiser Permanente Physicians believe no professionally acceptable alternative exists.

4.

When services for long-term rehabilitation are required; however, short-term (up to two months per condition) physical, occupational and speech therapy is covered.

E.

Termination of Individual Coverage

Coverage of the Covered Person as well as coverage of all Covered Dependents in the family unit under the Plan, shall automatically terminate on the earliest of the following dates:

1.

The date the Plan is terminated.

2.

The date on which any required Health Services fee has not been paid.

3.

In the case of a Covered Person who fails to pay a required Copayment Charge for Health Services performed, the date specified by Kaiser Permanente for termination of Coverage in written notice to the Covered Person with a copy to UCAR. Such notice shall be provided by Kaiser Permanente at least 15 days in advance of such termination.

4.

The date specified by Kaiser Permanente after 15 days' written notice if a Covered Person knowingly misrepresents his or her membership status or coverage, or knowingly presents an invalid prescription, or knowingly misuses or permits the misuse of a Kaiser Permanente identification card.

5.

The date a Covered Person's residence is no longer in a Kaiser Permanente Service Area. UCAR and the Covered Person shall be responsible for notifying Kaiser Permanente of a move from a Service Area. Coverage under the Plan will terminate on the date of such a move, even if such notice is not provided to Kaiser Permanente.

6.

The date UCAR receives written notice from the Participant requesting termination of Coverage, or the date requested by the Participant in such a notice, if later.

7.

The date specified by Kaiser Permanente, after 15 days' prior written notice to the Participant, that all Coverage for the Covered Person and all Covered Dependents in the family unit under the Plan will terminate due to the failure of the Participant to establish and maintain a satisfactory provider-patient relationship with any Kaiser Permanente Physician.

8.

The date on which the Covered Person ceases to be eligible as a Participant or Covered Dependent, including the date the Participant's employment will end when he or she is no longer actively working for UCAR. Except that, UCAR may, at its option, continue Coverage as shown below for individuals whose employment has ended, if it does so without individual selection between Participants, and if it continues making premium payments for those individuals.

Coverage may be continued for:

a.

Employees on certain types of leaves of absence, including medical leaves, in accordance with UCAR policy; and

b.

Employees who have been terminated due to a staff reduction can continue coverage for two months following termination at UCAR's expense. Coverage may be continued for an additional 16 months at the employee's expense. Note: If you receive a notice period rather than severance and then terminate voluntarily before that notice period ends, the two months of coverage at UCAR's expense will not be available to the employee.

Under certain circumstances, Covered Persons who cease to be eligible for Coverage under the Plan are entitled to continue Coverage under the Plan, as described in SECTION 5 - CONTINUATION AND CONVERSION.

9.

The date on which a Dependent no longer qualifies as a Dependent under this Plan, except that Dependents who cease to be eligible as Dependents may be entitled to continue Coverage under the Plan, as described in SECTION 5 - CONTINUATION AND CONVERSION.

10.

The date COBRA coverage terminates as specified in SECTION 5 - CONTINUATION AND CONVERSION.

11.

The date of death of the Covered Person.

January 2004