Acupuncture, Chiropractic, Naturopathy, Massage Therapy)

All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah St., Suite 100, Portland, OR 97232 ©2019 Kaiser Foundation Health Plan of the Northwest 337643167_LBG_04-19

Oregon PPO Plus® alternative care benefit (acupuncture, chiropractic, naturopathy, massage therapy)

This benefit covers self-referred acupuncture, chiropractic, naturopathic, and massage therapy services. You may choose providers from PPO providers or non-participating providers.

Choose your benefit maximum, 3 options: Benefit maximum per year (all services combined, all tiers combined) $1,000 / $1,500 / $2,000

Non-Participating PPO Providers Providers (Tier 1) (Tier 2)2

Services You Pay1 Specialty office visit Specialty office visit Acupuncture services cost share cost share Specialty office visit Specialty office visit Chiropractic services cost share cost share Specialty office visit Specialty office visit Naturopathic medicine cost share cost share Massage therapy (12-visit limit) $25 $25 1If added to an HSA-qualified deductible plan, this benefit is subject to the deductible. 2You may need to file a claim for covered services at non-participating providers.

Office visits You do not need a referral to make an appointment. There is no claim form to file for services from Tier 1 providers; you pay your copay or coinsurance directly to the provider when you receive care. Once your benefit limit has been reached, you pay 100% of the cost of services for the remainder of the calendar year.

PPO provider You may contact Member Services for additional information or visit kp.org/ppoplus/nw for information on locating a PPO provider.

Acupuncture services Acupuncturists influence the health of the body by the insertion of very fine needles. Acupuncture treatment is primarily used to relieve pain, reduce inflammation, and promote healing. Covered services include: ▪ Evaluation and management. ▪ Acupuncture. ▪ Electro acupuncture.

This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser Foundation Health Plan of the Northwest. Please see your Evidence of Coverage (EOC) for complete details of benefits as well as exclusions and limitations. In the event of a conflict between this summary and the EOC, the EOC will control. All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah St., Suite 100, Portland, OR 97232 ©2019 Kaiser Foundation Health Plan of the Northwest 337643167_LBG_04-19

Chiropractic services Chiropractic and manual manipulation of the spine, joints, or soft tissue focuses on reducing pain and improving the function and structure of the body. It is a system of therapy that involves noninvasive care promoting science-based approaches to a variety of ailments. Covered services include: ▪ Evaluation and management. ▪ Musculoskeletal treatments. ▪ Physical therapy modalities such as hot and cold packs.

When prescribed during a chiropractic visit, X-ray procedures may be covered, as described in your EOC.

Naturopathic medicine services Naturopathic medicine is a natural approach to health and healing that emphasizes a holistic approach to the diagnosis, treatment, and prevention of illness. Naturopathic physicians diagnose and treat patients by using natural modalities such as clinical nutrition, herbal medicine, and homeopathy. Covered services include evaluation and management.

When prescribed during a naturopathic medicine visit, certain laboratory tests may be covered, as described in your EOC.

Massage therapy services Therapeutic massage involves the manipulation of soft tissue structures of the body to help alleviate pain, muscle discomfort, and stress by helping to promote health and wellness. Covered services include evaluation and management.

Alternative care exclusions

▪ Acupressure. ▪ Health or exercise classes, ▪ Nambudripad allergy aids, or equipment. eliminated technique (NAET). ▪ Behavioral training and modification, including but not ▪ Hearing exams. ▪ Nerve conduction studies, limited to biofeedback, electromyography, ▪ Infertility services. hypnotherapy, play therapy, computerized muscle testing, and sleep therapy. ▪ The following laboratory or range of motion testing. services: ▪ Charges incurred as a result ▪ Obstetrical services. of missed appointment or an - Comprehensive digestive ▪ Over-the-counter drugs, appointment not canceled. stool analysis. medications (prescription or ▪ Chiropractic services in - Cytotoxic food allergy nonprescription) including excess of those necessary for test. vitamins, minerals, nutritional maximum chiropractic - Darkfield examination for or dietary supplements, or improvement. toxicity or parasites. any other supply or product, whether or not prescribed. ▪ Cosmetics, dietary - EAV and electronic tests supplements, recreation, for diagnosis or allergy. ▪ Physical examinations for health or beauty classes, - Fecal transient and evaluations and reports for aids, or equipment. retention time. licensing, school, sports, premarital, or those required ▪ Costs or charges incurred for - Henshaw test. for court proceedings. which the member is not - Intestinal permeability. legally required to pay. - Loomis 24-hour urine ▪ Point injection therapy (aquapuncture). ▪ Cupping. nutrient/enzyme analysis. - Melatonin biorhythm ▪ Preventive services. ▪ Dental services, including challenge. temporomandibular joint ▪ Proctology services. (TMJ) services. - Salivary caffeine clearance. ▪ Public facility care required ▪ Dermal friction technique. by federal, state, or local law. - Sulfate/creatine ratio. ▪ Disorders connected to - Thermography, hair ▪ Services considered military service. analysis, heavy metal experimental or investigational. ▪ Durable medical equipment, screening, and mineral devices, appliances, studies. ▪ Services designed to orthotics, or prosthetics. - Tryptophan load test. maintain optimal health in the absence of symptoms. ▪ Environmental - Urinary sodium benzoate. enhancements; modifications - Urine saliva pH. ▪ Smoking cessation. to dwellings, property, or - Zinc tolerance test. ▪ Sonopuncture. motor vehicles; adaptive equipment; personal ▪ Laserpuncture. ▪ Surgery. lodgings; travel expenses; ▪ Mental health services of any ▪ Transportation services. and meals. kind. ▪ Vocational rehabilitation. ▪ Fertility services, including ▪ Moxibustion. reversal of sterilizations. ▪ X-ray documentation and/or ▪ MRIs, diagnostic ultrasounds, interpretation when ▪ Gynecological services. CT scans, bone scans, and prescribed by an other special imaging studies. acupuncturist or naturopath.