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Personal Advantage

2009 individual and family plans

Health plans to help you THRIVE.

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Thank you for asking about Kaiser Permanente Personal Advantage.

With a wide variety of choices—and options starting at around

$75 a month*—you’re sure to find a health plan that meets

your needs.

No matter which plan you choose, Kaiser Permanente will be

your partner in total health. You’ll get care for the whole you—

mind, body, and spirit. You’ll have access to advantages you can use

every day. Like discounts on gym memberships, chiropractic care,

and massage therapy. And services like 24-hour health coaches,

health education classes, online health tools, and more. So you

can live well, be well, and thrive.

Get started now! The information in this booklet will help you

choose the plan that’s best for you and your family. Once you’ve

decided, just complete your application—or ask your broker how

to apply online and you’re one step closer to total health!

Welcome!

* For single male subscriber, age 12–19, in Plan 5,000. The rate you pay for your coverage depends on the plan you choose, your age and gender, and how many family members are enrolling. Rate charts are enclosed separately.

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Inside

The Kaiser Permanente advantage . . . . . . . . . . . . . . . . . . . . . . . . 3Learn why so many people in metro-Atlanta choose Kaiser Permanente to care for their health.

Your plan choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Review your many plan options, and find help choosing the one that’s right for you.

HMO plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8FAQs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

HMO plans with HSA option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13FAQs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Our privacy practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Read a description of how medical information about you may be used and disclosed, and how you can get access to it.

Additional information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Learn more about Personal Advantage coverage, our pharmacy formulary, preauthorization, exclusions, and more.

How to apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Find out how you can apply for Personal Advantage today!

Enclosed separately■ Your application ■ Personal Advantage Rates■ Balance Plans brochure

Questions?

Talk with your broker or call 1-800-792-2034.

The KaiserPermanenteadvantageYou’ve probably heard about

our dedication to quality

care, excellent service, and

convenience. But there are

many more reasons to make

Kaiser Permanente your

partner in health.

Great ChoicesWhether you’re looking for lowmonthly premiums, convenience andsimplicity, or tax savings, we have a plan to meet your needs. You can choose from a wide variety ofplans, with monthly rates starting ataround $75 a month.* And all plansinclude coverage for preventive care,hospitalization, and prescriptions.

Great care and serviceFor more than 20 years, KaiserPermanente has provided metro-Atlanta with quality health care that’s convenient, simple, and affordable.It’s our distinct approach to healthcare that keeps our members coming back year after year:

■ Total healthYou’ll like how we make it easier for you to take an active role in your own health—mind, body, and spirit. We help you live wellthrough online tools, health educa-tion classes, discounts on health-related services, and much more.And you’re covered for the preventive care you need, likeroutine physicals, well-child care, mammograms, immunizations, and more. So you can stay healthierand live your life to the fullest.

■ Personalized careNo matter which plan you choose,you select your own doctor. Whenyou choose a Kaiser Permanentedoctor, you’ll get quality care from adoctor who takes the time to get toknow you and your health needs.You’ll have all the things you needto get the personalized care youdeserve—compassionate peoplebacked by high-quality medical care,advanced technology, and leading-edge research.

■ ConvenienceWe make it easy to get the care youneed, when you need it. Whether it’slocations close to where you live orwork, seeing a physician when youneed one, or multiple services underone roof, we’ve got you covered.And you won’t have to worry aboutfiling claims when you visit ourmedical centers or any of our affiliated doctors and hospitals.

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The Kaiser P

ermanente ad

vantage

Healthy Solutions.

Get your own personal healthcoach 24 hours a day, 7 days a week by phone—at no cost—through Kaiser PermanenteHealthy Solutions.

■ Talk about tests or procedures, upcoming appointments, medications,diet, or exercise.

■ Get information about conditions, procedures, or general health and wellness.

■ Learn about new techniquesto help take control of spe-cific conditions or overallhealth.

■ Receive personalized check-in calls.

■ Get additional health infor-mation mailed to your home.

* For single male subscriber, age 12–19, in Plan 5,000. The rate you pay for your coverage depends on the plan you choose, your age and gender, and how many family members are enrolling. Rate charts are enclosed separately.

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You’re connected.

All of our medical centers areequipped with electronic patienthealth record systems. With yoursecure electronic health recordinstantly available right in the examrooms, you can enjoy more person-alized care based on your medicalhistory.

You can also enjoy the time-savingconvenience of these secure onlinefeatures:

■ E-mail your doctor’s office

■ View most lab test results

■ See past office visit informationand schedule most appointments

■ Monitor your ongoing health conditions

■ Access the health records of your children

■ And more!

You’ll also have the convenience ofmany other online services. On ourWeb site, kp.org, you can empoweryourself with many 24-hour healthresources including:

■ Online prescription refills

■ Nurse advice by e-mail

■ Health assessment tools

■ Personalized health improvementplans

■ Health encyclopedia

■ Kaiser Permanente Medical Centers

When you choose to get care at oneof our medical centers, you’ll seewhy members keep coming back:

■ Save time by seeing a doctor, getting lab tests or X-rays, andpicking up a prescription all in the same building.*

■ See a doctor at night or on week-ends at our after-hours locations.

■ Get a same-day appointment when available.

■ Receive quality, personalized care from a doctor who takes the time to listen.

* Available at most medical centers.

A few things that mightsurprise youWant more reasons to choose KaiserPermanente? Here are some that maysurprise you:

■ Wide selection of doctorsYou’ll have access to more than 2,000 doctors in the metro-Atlantaarea.

■ Easy accessYou can self-refer to select specialtiesincluding OB/GYN, dermatology,behavioral health, optometry, andophthalmology.

■ Travel coverageGet peace of mind knowing you’re covered for emergency care anywhere you travel.

■ Great discountsWe even make it more affordable to live healthy. Through ourSelfWise program, you can takeadvantage of a variety of health-related discounts** including:

■ Health club membership■ Massage therapy, chiropractic,

and acupressure services■ Vision care including eyeglasses

and contact lenses, and LASIK services

** Available to Kaiser Permanente members andtheir enrolled family members. Discounts andservices are provided on a fee-for-servicebasis, do not replace and cannot be com-bined with any existing benefit, and are notcovered benefits. Kaiser Permanente assumesno responsibility for the arrangement, nature,quality, or outcome of the services. For moreinformation, call (404) 261-2590.

Doctors and hospitals

■ over 2,000 doctors■ 20 affiliated hospitals

Your planchoices

Getting startedBefore you review the specific planinformation, check to make sure youlive within our Service Area. You'reeligible to apply for PersonalAdvantage coverage if you live inone of the following counties:Barrow, Bartow, Butts, Carroll,Cherokee, Clayton, Cobb, Coweta,DeKalb, Dawson, Douglas, Fayette,Forsyth, Fulton, Gwinnett, Hall,Haralson, Heard, Henry, Lamar,Meriwether, Newton, Paulding,Pickens, Pike, Rockdale, Spalding,and Walton.

Plans at a glanceIt’s not easy deciding which healthplan is right for you and your family.To make your decision a little easier,we give you a variety of affordableplans to choose from.

■ HMO plans (pages 6-10)

If you’re looking for great value andsimplicity, then one of our HMOplans could be the best option. Youcan choose from six plans, each withdifferent coverage and rates. If you want low copays and lowdeductibles, and are willing to pay a higher monthly premium for them,consider Premier Plan and Plan 500.If you want to keep your monthlypremium at a minimum, and are willing to pay more when you needcare and service, consider Plan 1,000,2,000, 3,000 or 5,000. No matterwhich plan you choose you can see a doctor for as low as $30. Thedeductibles only apply to specificbenefits. (See the benefit chart onpages 8-9 for more details.)

■ HMO plans with HSA option(pages 11-14)

If you’re interested in lowering yourpremiums and taking more controlover how you spend your healthcare dollars, take a look at our HMO plans with HSA option. Youcan enjoy low premiums, broad coverage, and the option to use a tax-free Health Savings Account(HSA) to pay for eligible medicalexpenses.1

These plans can be a great option if you/your family don’t have many doctor or hospital visits andprescriptions. You’ll generally havehigher out-of-pocket costs when you need care, but you’ll enjoy the predictable savings of lower premiums each month. (Except

for preventive care, all services—including office visits—will be subjectto the deductible.) You’ll also havethe option to open an HSA to pay for eligible medical expenses.Your HSA investment is tax-free and can carry over from year to year.

Rates and benefitsTake a closer look at your planoptions. For rates, check out thePersonal Advantage Rates insertenclosed separately. For coveragedetails, take a look at our HMOplans on pages 8-9 and our HMOplans with HSA option on page 13.

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You have choices!

HMO 6 plans

HMO plans 3 Self-Only planswith HSA 4 Family plans option

Your p

lan choices

Questions? Talk with your broker or call 1-800-792-2034.

It’s simple to apply!

Just complete and return yourapplication (enclosed separately)or ask your broker how to apply online. For more detailed instructions, see “How to apply”on page 23.

1Tax references relate to federal income tax only. The tax treatment of health savingsaccount contributions and distributions understate income tax laws differs from the federaltax treatment. Consult with your financial or taxadviser for more information.

When you choose a KaiserPermanente HMO plan, you’ll enjoytime-saving convenience and highquality, personalized care. You canchoose from six different HMOplans. They range from our afford-able plans with low copays and lowdeductibles, to plans with higherout-of-pocket costs in favor of lowmonthly premiums. With optionsstarting at around $75 a month,2

you’re sure to find a plan that fitsyour budget!

Here are a few good reasons tochoose Kaiser Permanente HMO:

■ Affordable coverageCopays for primary care visits areonly $30. And no matter which planyou choose, your affordable monthlypremiums include coverage for pre-ventive care, hospitalization, andprescriptions.

■ Wide selection of doctorsIn addition to doctors at our 15Kaiser Permanente Medical Centers,you’ll have access to 1,800 affiliated doctors practicing in their ownoffices all over town.

■ ConvenienceYou can save time by seeing a doctor and getting lab, X-ray, and pharmacy services all in one building—at most KaiserPermanente Medical Centers. Youcan also see a doctor at night or on weekends at one of several locations,3 get nurse advice 24 hoursa day by phone, or even make asame-day appointment at our medical centers when available.4

And you can order prescriptionrefills, request appointments, e-mail your doctor’s office, and view most lab results and past officevisit information right from home atkp.org.

■ Personalized CareYou have the freedom to chooseyour own personal physician, and tochange your mind for any reason.You’ll have a caring doctor whotakes the time to listen and get toknow you—so you can get the personalized care you deserve.

■ SimplicityYou won’t have to worry about filing claims when you visit ourmedical centers, or any of our affiliated doctors and hospitals.

■ AccessYou’ll have direct access to selectspecialties including OB/GYN, dermatology, optometry, ophthal-mology, and behavioral health.

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Lower your premiums

If you want low monthly premiums, check out Plan 1,000, 2,000, 3,000,

or 5,000. (See enclosed insert for rates.) Your out-of-pocket costs—

copays, coinsurance, and deductibles—will be higher than Premier Plan

and Plan 500 for many services, but your monthly premiums could be

significantly lower. To make your decision easier, the only differences

between Plans 1,000, 2,000, 3,000, and 5,000 are the deductibles and the

monthly premiums. (See the benefit chart on pages 8-9 for more details.)

HMO

2For single male subscriber, age 12–19, in Plan 5,000. The rate you pay for your coverage depends onthe plan you choose, your age and gender, and how many family members are enrolling. Rate charts are enclosed separately.

3Copays are higher for after-hours visits. See benefits chart on pages 8-9.

4Available to members receiving care at Kaiser Permanente Medical Centers.

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Where to get care

Our medical centersAlpharetta Medical Center3550 Preston Ridge RoadAlpharetta, GA 30005

Brookwood at Peachtree Medical Office1745 Peachtree St., Suite UAtlanta, GA 30309

Cascade Medical Center1175 Cascade ParkwayAtlanta, GA 30311

Crescent Medical Center200 Crescent Centre ParkwayTucker, GA 30084

Cumberland Medical Center*2525 Cumberland Parkway Atlanta, GA 30339

Forsyth Medical Office1400 Northside Forsyth Drive Suite 350Cumming, GA 30041

Glenlake Medical Center20 Glenlake ParkwayAtlanta, GA 30328

Gwinnett Medical Center*3650 Steve Reynolds Blvd.Duluth, GA 30096

Henry Towne Centre Medical Center1125 Towne Centre Village DriveMcDonough, GA 30253

Panola Medical Center5440 Hillandale DriveLithonia, GA 30058

Southwood Medical Center*2400 Mt. Zion ParkwayJonesboro, GA 30236

Stonecrest Medical Center8011 Mall ParkwayLithonia, GA 30038

Sugar Hill-Buford Medical Center1435 Broadmoor BoulevardSugar Hill, GA 30518

TownPark Medical Center750 TownPark LaneKennesaw, GA 30144

West Cobb Medical Center3640 Tramore Pointe ParkwayAustell, GA 30106

* Medical centers designated for after-hourscare. Hours: Monday through Friday, 6 to 9:30 p.m.; Saturday, 9 a.m. to 8:30p.m.; Sunday, 10 a.m. to 5:30 p.m.

Kaiser Permanente Medical Centers (15 locations)

Affiliated Community Physicians’Medical Offices (1,8 00 doctors)

H 20 Affiliated Hospitals*

* The hospital that you will be admitted to will be determined by the primary care physician you select.


For a current provider listing,

visit our searchable Medical Staff

Directory at kp.org/medicalstaff.

1. Deductible does not contribute to the out-of-pocket maximum. 2. Some benefits may have limitations. 3. Office visit copay may apply. Well-Child Visit: No Charge up to age 2. 4. Maternity charges for members are $1,000 for ob/gyn/midwife services (pre/post natal and delivery) and $2,000 for inpatient facility charge. Other charges may apply for otherprofessional services.

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Plan 500

Benefits shown with copays are not subject to deductible. You pay amount shown unless otherwise noted.

Premier Plan Plan 500

Deductible - Individual / Family None $500 / $1,500

Coinsurance Out-of-Pocket Max - Individual / Family1 Not Applicable $2,000 / $6,000

Maximum Benefit While Covered2Unlimited Unlimited

Coinsurance Not Applicable Plan pays 70% afterAnnual Deductible

Benefits

Office Services■ Primary Care $30 copay $30 copay

■ Specialty Care $50 copay $50 copay

■ Preventive Screenings3 Plan pays 100% Plan pays 100%

Pharmacy Services■ Rx Deductible - individual/family $200 / $600 $200 / $600

■ Generic Drugs - 30-day supply $15 copay/$21 copay $15 copay/$21 copayKaiser Permanente Medical Centers andDesignated Community Pharmacies

■ Brand Drugs - 30-day supply $30 copay/$36 copay $30 copay/$36 copayKaiser Permanente Medical Centers and Designated Community Pharmacies

■ Discount on mail order prescriptions (90-day supply) Mail Order available Mail Order available

Outpatient Services■ Laboratory Services Plan pays 100% Plan pays 100%

■ Radiology Services Plan pays 100% Plan pays 100%

■ High Tech Radiology Services (MRI, CT, PET, others) $100 copay Plan pays 70%

■ Outpatient Surgery Facility $100 copay Plan pays 70%

■ Hospital Outpatient Facility $100 copay Plan pays 70%

■ Physician and Other Professional Charges Plan pays 100% Plan pays 70%

Inpatient Services■ Hospital (facility charge) $500 per admission Plan pays 70%

■ Physician and Other Professional Charges Plan pays 100% Plan pays 70%

■ Inpatient Mental Health Facility - 30 days $500 per admission Plan pays 70%

Maternity Services■ Maternity (obstetrician/midwife)4 $1,000 copay $1,000 copay

■ Maternity (hospital delivery)4 $2,000 copay $2,000 copay

Emergency Services■ Emergency Room Visit (per visit; copay waived if admitted) $150 copay $150 copay

■ After-Hours Urgent Care (per visit) $60 copay $60 copay

■ Ambulance (per trip) $150 copay $150 copay

Other Services■ Vision Exam $50 copay $50 copay

■ Rehabilitation Therapies $50 copay Plan pays 70% (Physical, Occupational [20 visits], Speech [20 visits] Therapy)

2009 HMO benefit summaries

Benefits shown with copays are not subject to deductible. You pay amount shown unless otherwise noted.

This is a summary description and is not intended to replace the Individual Agreement or Personal Advantage Evidence of Coverage, which contain the complete provisions of this coverage. Some services require preauthorization. 9

Plan 1,000 Plan 2,000 Plan 3,000 Plan 5,000Plan 1,000 Plan 2,000 Plan 3,000

$1,000 / $3,000 $2,000 / $6,000 $3,000 / $9,000 $5,000 / $15,000

$2,000 / $6,000 $2,000 / $6,000 $2,000 / $6,000 $2,000 / $6,000

Unlimited Unlimited Unlimited Unlimited

Plan pays 70% after Plan pays 70% after Plan pays 70% after Plan pays 70% afterAnnual Deductible Annual Deductible Annual Deductible Annual Deductible

$30 copay $30 copay $30 copay $30 copay


Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100%

$200 / $600 $200 / $600 $200 / $600 $500 / $1,500

$15 copay/$21 copay $15 copay/$21 copay $15 copay/$21 copay $15 copay/$21 copay

$30 copay/$36 copay $30 copay/$36 copay $30 copay/$36 copay $30 copay/$36 copay

Mail Order available Mail Order available Mail Order available Mail Order available










$1,000 copay $1,000 copay $1,000 copay $1,000 copay

$2,000 copay $2,000 copay $2,000 copay $2,000 copay






Plan 5,000

Frequently asked questions—HMO

1. Do I have to go to KaiserPermanente’s Medical Centers to get care?

No. You’ll also have access to affiliat-ed private-practice doctors in theirown offices all over metro-Atlanta. Ifyou do choose to get care at ourmedical centers—as so many of ourmembers do—you’ll enjoy the convenience of being able to see a doctor and get lab, X-ray, and pharmacy services all in thesame building.

2. Can I see the doctor I have nowif I choose a Kaiser PermanenteHMO plan?

If your current primary care doctor is one of our 1,800 affiliated private-practice community physicians, youcan continue to see him or her. Ifyou have a specialist, and that personis part of our network, you may be able to see him or her as well. (You will need a referral from your Kaiser Permanente personalphysician for most specialty care.)

3. How do I find out which doctors are available?

Visit our searchable online Medical Staff Directory at kp.org/ medicalstaff. You can also refer tothe printed Kaiser Permanente HMO Physician Directory. If youwould like a copy, talk to your broker or call 1-800-792-2034.

4. What if I need emergency carewhen I’m traveling?

You’re covered for emergency orurgent care anywhere you travel.Receiving emergency or urgent careoutside of our metro-Atlanta ServiceArea is one of the few times youmay need to file a claim.

5. Can I cover just my kids if I want to?

Yes! You can get coverage for justyour children, just your spouse, justyourself, or any combination of theabove who live in our Service Area.Just choose the appropriate plan.

6. Can I pay just my copaymentsright away, or do I have to satisfymy deductible first?

Yes. For services that only require a copay, you can pay just yourcopay right from the start. With ourHMO plans, the annual deductibledoes not apply to physician visitsunless noted otherwise in thedescription of benefits.

7. How does coinsurance work?

With some plans, certain serviceshave deductibles and coinsuranceinstead of copays. Once you meet the deductible, you will beresponsible for paying a certain percentage—the coinsurance—of Eligible Charges.* The benefitschart on pages 8-9 shows whichservices have coinsurance.

8. Who should I call if I have aquestion?

Call your broker or call 1-800-792-2034 from 8 a.m. to 5 p.m. Monday through Friday.

10* Eligible Charges is the amount we use, in part, to determine your coinsurance; the amount to be applied toward an annual deductible or out-of-pocket

maximum; and, the amount used to determine the percentage we will pay.

Choosing Kaiser Permanente’s newHMO plans with HSA option can bea great way to lower your monthlypremiums. You can take advantageof the money you save on premiums by contributing to atax-advantaged Health SavingsAccount (HSA). The money in yourHSA can be used to pay for anyqualified medical expense. You canuse the money now, or you canbuild savings to pay for healthexpenses in the future.

Here are a few good reasons tochoose HMO plans with HSA option:

■ Affordability

You’ll enjoy low monthly premiumsand still have coverage for a broad range of services includingpreventive care, hospital visits, and prescriptions.

■ Tax savings

The money you contribute to your HSA can be excluded fromyour taxable income. It’s also tax-free when used to pay for qualified medical expenses. And any investment earnings in your HSA accumulate tax-free.

■ Investment opportunity

Through our preferred provider ofHSA services, Wells Fargo, you canchoose from a variety of funds foryour HSA. Investment results accu-mulate tax-free, and whatever you

don’t spend on medical expensescarries over from year to year.

■ Kaiser Permanente care andconvenience

HMO plans with HSA option giveyou access to our HMO network ofproviders—the doctors in our 15Medical Centers and over 1,800 private-practice doctors in their own offices all over metro-Atlanta.You’ll also be able to enjoy the timesaving convenience of multipleservices under one roof at most ofour medical centers. And you’llenjoy the great discounts and services available exclusively toKaiser Permanente members, like 24-hour health coaches, online tools, health classes, discounts onhealth clubs, and more.

Understanding our HMOplans with HSA optionYou can choose from three differentindividual plans or four differentfamily plans. The plans are designedto make things simple. Just choosethe plan with the annual deductible,coinsurance, and out-of-pocket max-imum that best meets your needs.

All services except pre ventive carewill be subject to the deductible.You’ll be responsible for paying thefull cost of the services you receiveat the time of service until you havesatisfied your plan’s deductible. Ifyou are enrolled in the HSA offeredby Wells Fargo, you can simply usethe convenient HSA Visa® debit cardto pay for your eligible expenses.The cost will be deducted from yourHSA. (Preventive care will either becovered 100 percent or at a $15copay, depending on the service.)

With our family plans, the deductiblecan be met by expenses for a com-bination of enrolled family members,or by expenses for just one member.

Once your annual deductible is met, you’ll just have to pay thecopayment or coinsurance, if any—until you reach your out-of-pocketmaximum. Once you’ve reachedyour out-of-pocket maximum, we’llpay 100 percent of your coveredservices for the remainder of the calendar year.

Enjoy the tax savings of an HSAIf you choose to take advantage ofan HSA, you can use your HSAfunds, tax-free, to pay for a broadrange of qualified medical expenses.Some of the many expenses HSAfunds can be used to pay for—whether or not they’re covered byyour plan—include:

■ Deductibles, copayments, andcoinsurance.

■ Glasses, LASIK eye surgery, andcontact lenses.

■ Dental and orthodontic services.

■ Prescription drugs and certainover-the-counter medications.

■ Certain types of alternative medicine services.

Any money from your HSA used topay for qualified medical expenses istax-free. For a complete listing ofqualified expenses under InternalRevenue Code Section 213(d), visitirs.gov/pub/irs-pdf/p502.pdf.

HMO plans withHSA option

11Questions? Talk with your broker or call 1-800-792-2034.

The money in your HSA—alongwith any invest ment earnings on it—will accumulate tax-free. And as theHSA account owner, the money isyours, even if you change qualifieddeductible health plans.

Experience the Wells Fargo advantageAlthough you can choose any finan-cial trustee for your HSA, we’ve chosen Wells Fargo as our preferredprovider of HSA services.

With the HSA offered by WellsFargo, you can choose from a variety of funds—from a conservative money market fund toan aggressive stock fund. You’ll alsohave no setup fees, an initial investment requirement of only$100, and no transaction fees. Plus, you can go online any timeand view account information,change investment fund elections,download forms, and access lists of covered expenses. And with the HSA Visa® debit card, paying for health services is as easy as theswipe of a card.

Invest in your futureWith an HSA, you can pay for healthcare expenses as they occur. Or, you

can save for the future by:

■ Building savings in the account topay for years when you havemore out-of-pocket expenses.

■ Keeping money not used duringworking years to be used for medical needs at retirement.

■ Investing money in the HSA andearning tax-free investment results.

■ After retirement age (65), usingthe money in an HSA for non-medical expenses withoutpenalty, taxed at your ordinaryincome rate.

Where to get careWith our HMO plans with HSAoption, you’ll have access to our HMO network of doctors. For a map of locations, please see page 7.

Note: Kaiser Permanente does not provide oradminister financial products, includingHSAs, and does not offer financial, tax, orinvestment advice. Members are responsible fortheir own investment decisions. If a memberuses his or her HSA debit card to pay for something other than a qualified medicalexpense, the expenditure is subject to tax and,for individuals who are not disabled or over65, a 10 percent tax penalty.

Please note that when Wells Fargo HealthBenefit Services pays disbursements, itdoes not monitor whether they are forqualified medical expenses. It is themember’s responsibility to determinewhether expenses qualify for tax-freereimbursement from his or her HSA. For information about a Wells FargoHSA, please contact Wells Fargo at 1-866-890-8308.

Tax references relate to federal incometax only. The tax treatment of health sav-ings account contributions and distribu-tions under state income tax laws differsfrom the federal tax treatment. Consultwith your financial or tax adviser formore information.

Earnings vary depending on the type ofinvestment plan you opt for and/or theHSA provider you choose. Amountearned is based on the investment planand market value, and in some instances,the account may actually lose money.

A lot to feel good about

■ Low premiums.

■ Great coverage including preventive care.

■ High quality care and service from Kaiser Permanente.

■ Tax-free health savings.

■ An investment that can build from year to year.

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HMO plans with HSA optionBenefits Summary

SELF-ONLY PLANS FAMILY PLANS (2+)

HSA Option HSA Option HSA Option HSA Option HSA Option HSA Option HSA Option3,500/100% 5,000/100% 3,500/80% 3,500/100% 5,000/100% 3,500/80% 5,000/80%Self Self Self Family Family Family Family

Annual Deductible $3,500 $5,000 $3,500 $3,500 $5,000 $3,500 $5,000

Out-of-Pocket Maximum $3,500 $5,000 $5,000 $3,500 $5,000 $7,500 $9,000

Coinsurance Plan pays Plan pays Plan pays Plan pays Plan pays Plan pays Plan pays 100% after 100% after 80% after 100% after 100% after 80% after 80% afterAnnual Annual Annual Annual Annual Annual AnnualDeductible Deductible Deductible Deductible Deductible Deductible Deductible

Maximum Benefit whileCovered

Preventive Visits

Preventive Services

All Other Covered Services

This plan summary is intended to only highlight some of the principal provisions of the plan. Please refer to your Evidence ofCoverage for further details of the plan, or for specific limitations and exclusions. Certain underwriting guidelines apply. Applicants subject to medical review.

UnlimitedUnlimited

$15 Copay$15 Copay

Subject to Annual Deductible and CoinsuranceSubject to Annual Deductible and Coinsurance

Plan pays 100% (Annual Deductible not applicable)

Plan pays 100% (Annual Deductible not applicable)

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Common Questions—HMO plans with HSA option

Q: How do I apply for an HMOplan with HSA option?

A: Just fill out a MembershipApplication for Personal Advantageand choose the appropriate plan. Ifyou need an application, talk toyour broker or call 1-800-792-2034Monday-Friday 8 a.m.-5 p.m.

Q: What doctors can I see with anHMO plan with HSA option?

A: You’ll have access to the KaiserPermanente HMO network ofproviders—doctors at our 15 MedicalCenters and over 1,800 private-prac-tice doctors in their own offices allover metro-Atlanta. You can receivequalified medical services from otherproviders, but you’ll be responsiblefor the full cost of these services.(However, you can pay for themwith money from your HSA.)

Q: How do the deductible and theOut-of-Pocket (OOP) maximumwork for families?

A: There is just one deductible forthe whole family. The deductiblemay be satisfied by expensesincurred by one family member,or by a combination of family mem-bers. Once the deductible has beensatisfied during a calendar year, allfamily members are exempt fromany further deductible requirementsfor that year.

The OOP maximum works in a simi-lar way. Eligible expenses for onefamily member or any combinationof family members can satisfy theOOP maximum for the whole family.

Once the OOP maximum is reached,Kaiser Permanente pays for 100 per-cent of covered services for theentire family for the remainder ofthe calendar year.

Q: Who is eligible for an HSA?

A: To be eligible to establish andmake a contribution to an HSA, youhave to be covered by a qualifyinghigh deductible health plan, like ourHMO plans with HSA option. Also, you may not be covered byother health insurance that’s not aqualifying deductible health plan,although there are certain exceptions.(Some of the exceptions includeworkers’ compensation, specificinjury insurance, and insurance foraccidents, disability, dental care,vision care, or long-term care. You may also have coverage for aspecific disease or illness as long asit pays a specific dollar amountwhen the policy is triggered.) Youare not eligible to contribute to anHSA if you are enrolled in Medicareor able to be claimed as a dependenton someone else’s tax return, or ifyou have received medical benefitsfrom the Depart ment of VeteransAffairs at any time over the pastthree months.

Q: How do I set up an HSA?

A: You can establish an HSA at anyapproved HSA financial provider. For added convenience, KaiserPermanente members can set up anHSA through Wells Fargo, our pre-ferred HSA trustee and administrator.You can sign up online or call WellsFargo for enrollment materials.

Visit wfhbs.com/kaiserpermanente, or call a Wells Fargo HSA customer service representative at 1-866-890-8308 Monday-Friday 8 a.m.-8 p.m. (EST).

Q: How much can be contributedto my HSA?

A: Annual contributions for 2009 are capped at $3,000 for individual coverage and $5,950 for family coverage. For 2009 and after, thesemaximums will be indexed for inflation.

Q: Where can I get more information about KaiserPermanente’s HMO plans with HSA option?

A: For more information, call yourbroker or call 1-800-792-2034Monday-Friday 8 a.m.-5 p.m.

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As part of a Georgia state law, youhave another option available to youthrough Kaiser Permanente PersonalAdvantage called the ConsumerChoice Option. This option can beadded to any of our PersonalAdvantage plans.

■ With Consumer Choice Option,you can nominate and use providersnot normally available throughKaiser Permanente.

■ You still receive benefits com-parable to those you would receivewhen using in-plan or Selectproviders.

■ This option costs 17.5 percentmore than what is quoted in therates for 2009.

If you would like more informationon the Consumer Choice Option—including an election form, informa-tion on how to nominate a provider,and rate information—please call our Consumer Choice Option representative at (404) 364-4900.

If you think you would be interestedin enrolling in the Consumer ChoiceOption, please wait until after youreceive and review the materials toreturn your medical questionnaire.The medical questionnaire andConsumer Choice Option electionform must be returned to KaiserPermanente at the same time.

Our privacypracticesNotice of PrivacyPracticesThis notice describes how medicalinformation about you may be usedand disclosed and how you can getaccess to this information. Pleasereview it carefully.

In this notice we use the terms “we,” “us” and “our” to describe theKaiser Permanente, Georgia Region.For more details, please refer to section IV. of this notice.

I. What is “ProtectedHealth Information?”Your protected health information(PHI) is health information that con-tains identifiers, such as your name,social security number, or other infor-mation that reveals who you are. Forexample, your medical record is PHIbecause it includes your name andother identifiers.

If you are a Kaiser Foundation HealthPlan member and also an employeeof any Kaiser Permanente company,PHI does not include the health infor-mation in your employment records.

In the course of providing andadministering health care, we collectvarious types of health informationfrom various sources, such as you,

other members (for example, yourspouse or parents), and other healthcare professionals. The types of infor-mation we collect and maintain aboutour members include among otherthings, medical and hospital records,such as general medical, mentalhealth, and substance abuse patientrecords, laboratory results, X-rayresults, pharmacy records, andappointment records. KaiserPermanente collects other health plan information using a variety of techniques. Examples include:

■ Collecting information from youthrough surveys, applications,related forms, and other writtenrequests and communications;

■ Collecting information from youremployer, benefits plan sponsor,or association regarding groupcoverage that you may havethrough group applications, census data, and other writtenrequests and communications;

■ Collecting information from visitors to our Web site such asonline forms, site visit data, andother on-line communications; and

■ Collecting information from consumer or medical reportingagencies or other sources such asinsurance support organizationsand credit bureaus.

Consumer ChoiceOption

Privacy p

ractices

II. About our responsi-bility to protect your PHIBy law, we must

1) protect the privacy of your PHI;

2) tell you about your rights and ourlegal duties with respect to yourPHI; and

3) tell you about our privacy practices and follow our noticecurrently in effect.

We take these responsibilities seriously and, as in the past, we willcontinue to take appropriate steps tosafeguard the privacy of your PHI.

III. Your rights regardingyour PHIThis section tells you about yourrights regarding your PHI, for exam-ple, your medical and billing records.It also describes how you can exer-cise these rights.

Your right to see and receivecopies of your PHI In general, you have a right to seeand receive copies of PHI in desig-nated record sets such as your med-ical record or billing record. If youwould like to see or receive a copyof such a record, please write to us. When you know the KaiserPermanente facility or medical center where you received your care,please write to us at that address. If you don’t know where yourrecords that you want to see arelocated, please write to us at Customer Service Department; Kaiser Foundation Health Plan ofGeorgia, Inc.; Nine Piedmont Center;

3495 Piedmont Road, NE; Atlanta,Georgia 30305-1736.

After we receive your written request,we will let you know when and howyou can see or obtain a copy of yourrecord. If you agree, we will give youa summary or explanation of yourPHI instead of providing a copy.

We may charge you a fee for thecopy, summary, or explanation. If we don’t have your record but weknow who does, we will tell youwho to contact to request it.

In limited situations, we may denysome or all of your request to see orreceive a copy of your records, but if we do, we will tell you why inwriting and explain your right, if any, to have our denial reviewed.

Your right to choose how we send PHI to youYou may ask us to send your PHI to you at a different address (forexample, your work address) or bydifferent means (for example, faxinstead of regular mail). When wecan reasonably and lawfully agree toyour request, we will. However, weare permitted to charge you for any additional cost of sending your PHI to different addresses or by different means.

Your right to correct or update your PHIIf you believe there is a mistake inyour PHI or that important informa-tion is missing, you may request that we correct, delete, or add to the record. Please write to us and tell us what you are asking for andwhy we should make the correction,deletion, or addition. Your request

should be sent as described above in the section entitled “Your right tosee and receive copies of your PHI.”If we approve your request, we will make the correction or additionto your PHI. If we deny your request,we will tell you why and explainyour right to file a written statementof disagreement.

Your right to an accounting of disclosures of PHIYou may ask us for a list of our dis-closures of your PHI. If you wouldlike a list of disclosures, please writeto us as described above in the section entitled “Your right to see and receive copies of your PHI.” The list we give you will include disclosures made in the last six years,unless you request a shorter timeperiod or if fewer than six years have passed since April 14, 2003. For example, if you requested a list of disclosures on April 14, 2005,the list would cover only two years.

You are entitled to one disclosureaccounting in any 12-month period at no charge. If you request any additional accountings fewer than 12 months later, we may charge a fee.

Except as may otherwise be requiredunder state law, an accounting doesnot include certain disclosures, forexample, disclosures to carry outtreatment, payment and health careoperations; disclosures that occurredprior to April 14, 2003; disclosures forwhich Kaiser Permanente, GeorgiaRegion had a signed authorization;disclosures of your PHI to you; dis-closures for notifications for disasterrelief purposes; or disclosures to persons involved in your care andpersons acting on your behalf.

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Your right to request limits on uses and disclosures of your PHIYou may request that we limit our uses and disclosures of your PHIfor treatment, payment, and healthcare operations purposes. However,by law, we do not have to agree toyour request. Because we stronglybelieve that this information is needed to manage care of our members/patients appropriately, it is our policy not to agree torequests for restrictions.

Your right to receive a papercopy of this noticeYou also have a right to receive a paper copy of this notice uponrequest.

IV. Kaiser Permanentecompanies subject to thisnoticeThis notice applies to the KaiserPermanente, Georgia Region whichincludes:

■ The Southeast Permanente MedicalGroup, Inc. (TSPMG)

■ Kaiser Foundation Health Plan ofGeorgia, Inc. including its healthplan and provider operations;

■ Kaiser Foundation Hospitals(KFH), as described below; and

■ Kaiser Foundation Health Plan,Inc. (KFHP, Inc.), as describedbelow

Our health care delivery sites include Kaiser Permanente medicalcenters, our member call advice and appointment centers, and ourmember Web site.

To provide you with the health careyou expect when treating you, pay-ing for your care, and conducting ouroperations, such as quality assurance,accreditation, licensing and compli-ance, these Kaiser Permanente com-panies share your PHI with eachother.

Our personnel may have access toyour PHI as employees, physicians,volunteers, persons working with usin other capacities, or professionalstaff members and others authorizedto enter information into a medicalrecord of a Kaiser PermanenteMedical Center. Our region may also share your PHI with KFH andKFHP, Inc. in connection with sharedservices and other national KaiserPermanente activities for treatment,payment, or health care operationspurposes. For example, if you arebeing considered for a transplant, we will share your PHI with ourKaiser Permanente NationalTransplant Network.

V. How we may use anddisclose your PHIYour confidentiality is important tous. Our physicians and employeesare required to maintain the confi-dentiality of the PHI of our mem-bers/patients and we have policies

and procedures and other safeguardsto help protect your PHI fromimproper use and disclosure. Some -times we are allowed by law to useand disclose certain PHI without your written permission. We brieflydescribe these uses and disclosuresbelow and give you some examples.

How much PHI is used or dis closedwithout your written permission willvary depending, for example, on theintended purpose of the use of dis-closure. Sometimes we may onlyneed to use or disclose a limitedamount of PHI, such as to send youan appointment reminder or to confirm that you are a health planmember. At other times we may need to use or disclose more PHIsuch as when we are providing medical treatment.

Treatment This is the most important use anddisclosure of your PHI. For example,our physicians, nurses, and otherhealth care personnel, includingtrainees, involved in your care useand disclose your PHI to diagnoseyour condition and evaluate yourhealth care needs. Our personnel will use and disclose your PHI inorder to provide and coordinate the care and services you need, forexample: prescriptions; X-rays; andlab work. If you need care fromhealth care providers who are notpart of Kaiser Permanente, such ascommunity resources to assist withyour health care needs at home, wemay disclose your PHI to them.

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Treatment alternatives andhealth-related benefits andservices In some instances, the law permits us to contact you: 1) to describe ournetwork or describe the extent towhich we offer and pay for variousproducts and services; 2) for yourtreatment; 3) for case managementand care coordination; or 4) to director recommend available treatmentoptions, therapies, health care pro -viders, or care settings. For example,we may tell you about a new drug orprocedure or about educational or health management activities.

Payment Your PHI may be needed to deter-mine our responsibility to pay for, or to permit us to bill and collect payment for, treatment and health-related services that you receive. Forexample, we may have an obligationto pay for health care you receivefrom an outside provider. When you or the provider sends us the billfor health care services, we use and disclose your PHI to determine howmuch, if any, of the bill we areresponsible for paying.

Health care operationsWe may use and disclose your PHIfor certain health care operations,such as: quality assessment andimprovement; training and evaluationof health care professionals; licensing;accreditation; activities relating to thecreation, renewal or replacement ofhealth insurance or health benefits;conducting medical review; legal

services; auditing functions, includ-ing fraud and abuse detection andcompliance programs; customer services; and determining premiumsand other costs of providing healthcare. We may also disclose your PHIfor certain health care operations ofother health plans and health careproviders.

Business associatesWe may contract with business associates to perform certain func-tions or activities on our behalf, such as payment and health careoperations. These business associatesmust agree to safeguard your PHI.

Appointment remindersYour PHI allows us to contact youabout appointments for treatment orother health care you may need.

Specific types of PHIThere are stricter requirements foruse and disclosure of some types ofPHI, for example, drug and alcoholabuse patient information, mentalhealth records, and HIV/AIDS infor-mation. However, there are still circumstances in which these types of information may be used or dis-closed without your authorization.

If you become a patient in our chemical dependency program, wewill give you a separate writtennotice, as required by law, aboutyour privacy rights for your chemicaldependency program PHI.

Communications with family andothers when you are presentSometimes a family member or otherperson involved in your care will bepresent when we are discussing yourPHI with you. If you object, pleasetell us and we won’t discuss your PHIor we will ask the person to leave.

Communications with family and others when you are not presentThere may be times when it is necessary to disclose your PHI to a family member or other personinvolved in your care because thereis an emergency, you are not present,or you lack the decision makingcapacity to agree or object. In thoseinstances, we will use our profession-al judgment to determine if it’s inyour best interest to disclose yourPHI. If so, we will limit the disclosureto the PHI that is directly relevant to the person’s involvement withyour health care. For example, wemay allow someone to pick up a prescription for you.

Disclosure in case of disasterreliefWe may disclose your name, city ofresidence, age, gender, and generalcondition to a public or private disaster relief organization to assistdisaster relief efforts, unless youobject at the time.

Disclosures to parents as person-al representatives of minorsIn most cases, we may disclose yourminor child’s PHI to you. In some situations, however, we are permittedor even required by law to deny

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your access to your minor child’sPHI. Examples of when we mustdeny such access include situationsinvolving your daughter’s pregnancy,the prevention of her pregnancy,childbirth, and abortion recordswhere a court waives parental notification of abortion. In addition,the law denies access to your child’sPHI if your child is married or otherwise emancipated.

ResearchKaiser Permanente engages in ex ten -sive and important research. Some ofour research may involve medicalprocedures and some is limited tocollection and analysis of health data.Research of all kinds may in volve theuse or disclosure of your PHI. YourPHI can generally be used or dis-closed for research without your permission if an Institutional ReviewBoard (IRB) approves such use ordisclosure. An IRB is a committee that is responsible, under federal law,for reviewing and approving human subjects research to protect the safety of the participants and the confidentiality of PHI.

Organ donationExcept as limited by applicable law, we may use or disclose PHI to organ-procurement organizations toassist with organ, eye, or other tissuedonations.

Public health activitiesPublic health activities cover manyfunctions performed or authorized bygovernment agencies to promote andprotect the public’s health and mayrequire us to disclose your PHI.

For example, we may disclose yourPHI as part of our obligation to re-port to public health authorities certain diseases, injuries, conditions,and vital events such as births orabortions. Sometimes we may dis-close your PHI to someone you mayhave exposed to a communicable disease, or who may otherwise be at risk of getting or spreading the disease.

The Food and Drug Adminis tration(FDA) is responsible for tracking andmonitoring certain medical products,such as pacemakers and hip replace-ments, to identify product problemsand failures and injuries they mayhave caused. If you have receivedone of these products, we may use and disclose your PHI to the FDA or other authorized persons or organizations, such as the maker of the product.

We may use and disclose your PHI as necessary to comply with federaland state laws that govern workplacesafety.

Health oversightAs health care providers and healthplans, we are subject to oversightconducted by federal and state agen-cies. These agencies may conductaudits of our operations and activitiesand in that process, they may reviewyour PHI.

Disclosures to your employer or your employee organizationIf you are enrolled in KaiserFoundation Health Plan of Georgiathrough your employer or employee

organization, we may share certainPHI with them without your authori-zation but only when allowed bylaw. For example, we may discloseyour PHI for a workers compensationclaim or to determine whether youare enrolled in the plan or whetherpremiums have been paid on yourbehalf. For other purposes, such as for inquiries by your employer or employee organization on your behalf, we will obtain yourauthorization when necessary.

Workers’ compensationIn order to comply with workers’compensation laws, we may use and disclose your PHI. For example,we may communicate your medicalinformation regarding a work-relatedinjury or illness to claims administra-tors, insurance carriers, and othersresponsible for evaluating your claimfor workers’ compensation benefits.

Military activity and nationalsecurityWe may sometimes use or disclosethe PHI of armed forces personnel to the applicable military authoritieswhen they believe it is necessary toproperly carry out military missions.We may also disclose your PHI to authorized federal officials as necessary for national security andintelligence activities or for protectionof the President and other govern-ment officials and dignitaries.

MarketingKaiser Permanente may use and, insome instances, disclose your PHI tocontact you about benefits, servicesor supplies that we can offer you inaddition to your KP coverage.

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FundraisingWe may use or disclose PHI to contact you to raise funds for ourorganization.

Required by lawIn some circumstances federal orstate law requires that we discloseyour PHI to others. For example, the Secretary of the Department ofHealth and Human Services mayreview our compliance efforts, which may include seeing your PHI.

Lawsuits and other legal disputesWe may use and disclose PHI inresponding to a court or administra-tive order, a subpoena, or a discoveryrequest. We may also use and dis-close PHI to the extent permitted by law without your authorization,for example, to defend a lawsuit or arbitration.

Law enforcementWe may disclose PHI to authorizedofficials for law enforcement purpos-es, for example, to respond to asearch warrant, report a crime on our premises, investigate fraud, orhelp identify or locate someone.

Serious threat to health or safety We may use and disclose your PHI if we believe it is necessary to avoida serious threat to your health orsafety or to someone else’s.

Abuse or neglectBy law, we may disclose PHI to theappropriate authority to report sus-pected child abuse or neglect or toidentify suspected victims of abuse,neglect, or domestic violence.

Coroners and funeral directorsWe may disclose PHI to a coroner or medical examiner to permit identi-fication of a body, determine causeof death, or for other official duties.We may also disclose PHI to funeral directors.

InmatesUnder the federal law that requires usto give you this notice, inmates donot have the same rights to controltheir PHI as other individuals. If you are an inmate of a correctionalinstitution or in the custody of a lawenforcement official, we may discloseyour PHI to the correctional institu-tion or the law enforcement officialfor certain purposes, for example, to protect your health or safety orsomeone else’s.

VI. All other uses and disclosures of your PHIrequire your prior writtenauthorizationExcept for those uses and disclosuresdescribed above, we will not use ordisclose your PHI without your writ-ten authorization. When your authori-zation is required and you authorizeus to use or disclose your PHI forsome purpose, you may revoke

that authorization by notifying us inwriting at any time. Please note thatthe revocation will not apply to anyauthorized use or disclosure of yourPHI that took place before wereceived your revocation. Also, if you gave your authorization to securea policy of insurance, includinghealth care coverage from us, youmay not be permitted to revoke it until the insurer can no longer contest the policy issued to you or a claim under the policy.

VII. How to contact usabout this notice or tocomplain about our privacy practicesIf you have any questions about thisnotice, or want to lodge a complaintabout our privacy practices, please let us know by calling or writing to Customer Service Department;Kaiser Foundation Health Plan ofGeorgia, Inc.; Nine Piedmont Center;3495 Piedmont Road, NE; Atlanta,Georgia 30305-1736.

If you are enrolled in a plan otherthan Senior Advantage, you may callCustomer Service at (404) 261-2590.Its hours of operation are Mondaythrough Friday from 7 a.m. to 9 p.m.and Saturday through Sunday from 8 a.m. through 2 p.m. If you areenrolled in Senior Advantage, youmay call the Senior AdvantageCustomer Service Department at (404) 233-3700 or toll free at 1-800-232-4404 (TTY: 1-800-255-0056).Its hours of operation are Monday

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through Friday from 8 a.m. to 8 p.m.You also may notify the Secretary of the Department of Health andHuman Services (HHS).

We will not take retaliatory actionagainst you if you file a complaintabout our privacy practices.

VIII. Changes to thisnoticeWe may change this notice and ourprivacy practices at any time, as longas the change is consistent with stateand federal law. Any revised noticewill apply both to the PHI we alreadyhave about you at the time of thechange, and any PHI created orreceived after the change takes effect.If we make an important change to our privacy practices, we willpromptly change this notice and pro-vide a new notice on our memberWeb site at kp.org and our memberpublication, Partners in Health.Except for changes required by law,we will not implement an importantchange to our privacy practicesbefore we revise this notice.

IX. Effective date of this noticeThis notice is effective on April 14, 2003.

Additionalinformation

About your PersonalAdvantage coverageBefore you review the specific plan information, check to makesure you live within our ServiceArea. You're eligible to apply forPersonal Advantage coverage if youlive in one of the following counties:Barrow, Bartow, Butts, Carroll,Cherokee, Clayton, Cobb, Coweta,DeKalb, Dawson, Douglas, Fayette,Forsyth, Fulton, Gwinnett, Hall,Haralson, Heard, Henry, Lamar,Meriwether, Newton, Paulding,Pickens, Pike, Rockdale, Spalding,and Walton.

You can apply for Kaiser PermanentePersonal Advantage until age 65.However, please note that coveragecan end for failure to pay premiumswhen due, or for misrepresentationof medical or other important information on your application.

When you turn 65 or become eligible for Medicare, you have the option to apply for our SeniorAdvantage plan. If you are alreadyeligible for Medicare as your primarycoverage, you are not eligible for Personal Advantage, but you canapply for Senior Advantage. You can ask about our coverage forMedicare-eligible members by calling toll-free 1-888-468-0100.

If you have any questions or would like more information, just ask your broker or call1-800-792-2034.

Drug FormularyKaiser Permanente uses a drug formulary for our HMO plans and HMO plans with HSA option.Our drug formulary is a continuallyupdated list of medications that aredetermined to be safe and effective.Use of formulary drugs enables us to provide quality care at a reasonable cost.

If you request a nonformulary drug,you will be responsible for the fullcost of that drug, unless there is aclear medical reason to use it ratherthan the similar formulary drug. Inspecific cases, such as allergy to theformulary alternative, your physicianmay request an exception for cover-age of a nonformulary drug at yourregular pharmacy copay. Certainprescriptions require expert reviewbefore they can be dispensed.

If you have any questions about theformulary, call 1-800-232-4404.

AuthorizationWhen you need to obtain preauthorization for covered services, or have a question aboutwhether a service requires pre-authorization, please contact theKaiser Permanente UtilizationManagement Department at (404)364-7320 or 1-800-221-2412.

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At Kaiser Permanente, the UtilizationManagement Program works withParticipating Providers to plan, organ-ize, and deliver quality health careservices by ensuring these services are medically appropriate, medicallynecessary, and provided in a cost-effective manner. Some servicesrequire preauthorization by theUtilization Management Program.Examples include, but are not limited to:

■ Elective inpatient admissions.

■ Outpatient surgery.

■ Specialized services such as home health, medical supplies/equipment, and hospice care.

■ Skilled nursing and acute rehabilitation facilities.

■ Certain behavioral health servicesand/or chemical dependency treatment.

Failure to obtain preauthorizationmay result in penalties against yourbenefit payment, or we may denyall or part of your claim. In theevent any service is denied becauseit does not meet criteria, you mayrequest an appeal.

ExclusionsAs with all health plans, there aresome exclusions. The following serv-ices are excluded from all coverage.(Please note that this is a summary—for a complete list, refer to thePersonal Advantage Evidence ofCoverage.)

■ Services which an employer or any government agency is re-sponsible to provide, including workers’ compensation

■ Custodial care or care in an intermediate care facility

■ Services provided or arranged bycriminal justice institutions ormental health institutions forMembers in the custody of lawenforcement officers if you areconfined in the institution, exceptfor emergency services

■ Cosmetic services (including drugs and injectables)

■ Cord blood procurement and storage for possible future need or for a yet-to-be determined member recipient

■ Dental services, devices and appliances other than those specified (including most hospital services for dental care)

■ Physical examinations required for obtaining or maintainingemployment or participation inemployee programs, or insuranceor government licensing

■ Experimental or investigational services

■ Refractive surgery or corrective lenses, eyeglasses, and hearing aids

■ Orthoptics (eye exercises)

■ Services and drugs related to the treatment of obesity

■ Routine foot care services

■ Examinations for the prescription of hearing aids

■ All services and drugs related to sexual reassignment surgery

■ Long-term physical, speech, and occupational therapy and rehabilitation

■ Cognitive rehabilitation programs

■ Vocational rehabilitation

■ Services that are primarily educational in nature

■ Cost of semen and eggs

■ Services for conception by artificial means including infertility drugs

■ Reversal of voluntary infertility

■ Nonhuman and artificial organs and their implantation

■ Court-ordered services

■ Mental health services for chronic conditions and mental retardation after diagnosis

■ Testing for ability, aptitude, intelligence, or interest

■ Corrective shoes and orthotic foot supports and inserts

■ More than one device for the same part of the body or same function

■ Replacement of lost devices

■ Electronic monitors of bodily functions (except infant apnea monitors and blood glucose monitors)

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

■ Devices not medical in nature

■ Convenience, comfort, or luxury items

■ Reconstructive surgery following removal of breast implants that were inserted for cosmetic reasons

■ Drugs for the treatment of sexual dysfunction disorders

■ Most disposable supplies

■ Transportation and lodging

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Who provides the coverageHMO and Balance plans are provided by Kaiser FoundationHealth Plan, Inc.

This is only a summaryThis is a summary description and is not intended to replace yourIndividual Agreement or PersonalAdvantage Evidence of Coverage,which contain the complete provi-sions of this coverage. If you havequestions or need additional infor-mation, please call 1-800-232-4404.

For more informationHave a question that’s not answeredin this information kit? Just call yourbroker or call 1-800-792-2034.

How toapplyIt’s simple to apply. Once you’vechosen a plan, just follow the stepsbelow.

To apply by mail1. Make sure you live in one of thecounties we serve: Barrow, Bartow,Butts, Carroll, Cherokee, Clayton,Cobb, Coweta, DeKalb, Dawson,Douglas, Fayette, Forsyth, Fulton,Gwinnett, Hall, Haralson, Heard,Henry, Lamar, Meriwether, Newton,Paulding, Pickens, Pike, Rockdale,Spalding, and Walton.

2. Fill out the MembershipApplication for Personal Advantage,enclosed separately. Complete all the requested information toavoid delays. Be sure to sign it andcomplete the Payment Optionssection.

3. Mail the following items in thepostage-paid envelope providedinside the application:

■ Your completed and signedapplication

■ A check for the first month’s premium (unless you select thePayment by Credit Card option)

To apply onlineAsk your broker how to applyonline. If you don’t have a broker,call 1-800-792-2034 from 8:00 a.m.to 5 p.m. (EST), Monday throughFriday (except holidays).

Once we receive your application, itwill be processed in approximatelyseven business days. (To be eligiblefor Personal Advantage, your appli-cation must pass medical review.)Then, we’ll send you a letter notify-ing you whether or not you havebeen approved for coverage. Wewon’t deposit your check or chargeyour credit card unless you’reaccepted for membership.

Please do not cancel your current coverage. Personal Advantage cover-age will not begin until you receivea written notice of approval. Ifapproved, your coverage will beginon the effective date indicated onthe notice.

Apply today!

Just complete your application(enclosed separately) or ask your broker how to apply online.

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Notes

60028401 11/08 for Q1.09BR ©2008 Kaiser Foundation Health Plan of Georgia, Inc.

Personal Advantage 1-800-792-2034

Apply today!

Personal Advantage

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