KEHP_2025_BSG.pdf — PaddleOCR-VL (Baidu)

Benefits Grid

Plan Options	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network
	LivingWell CDHP		LivingWell PPO		LivingWell Basic CDHP		LivingWell HDHP
Diagnostic tests in doctor's office	Deductible, then 20%	Deductible, then 50%	Office Visit Co-pay	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Surgery in Office Setting	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Behavioral Health and Substance Abuse Use	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Autism Services	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Allergy Injection without Office Visit	Deductible, then 20%	Deductible, then 50%	$15 Co-pay	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Allergy Serum	Deductible, then 20%	Deductible, then 50%	$15 Co-pay	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Chiropractic Care (manipulation therapy) (maximum of 26 visits per year, no more than one visit a day)	Deductible, then 20%	Deductible, then 50%	$25 Co-pay	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Therapy Services (per visit: physical, occupational, speech - maximum combined limit of 90 visits per year)	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Emergency Services
Urgent Care Center	Deductible, then 20%		$50 Co-pay		Deductible, then 30%		Deductible, then 30%
Emergency Room (emergency medical treatment only)	Deductible, then 20%		$150 Co-pay, then Deductible, then 25%. Co-pay waived if admitted.		Deductible, then 30%		Deductible, then 30%
Emergency Room Physician	Deductible, then 20%		Deductible, then 25%		Deductible, then 30%		Deductible, then 30%
Ambulance	Deductible, then 20%		Deductible, then 25%		Deductible, then 30%		Deductible, then 30%
Other Services
Inpatient Hospital (Semi-private room)	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Outpatient Hospital/Surgery	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Outpatient/Ambulatory Surgery Center	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Maternity Care	Deductible, then 20%	Deductible, then 50%	$25 Co-pay (office visit pregnancy diagnosed) Delivery Charge: Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
Durable Medical Equipment and Supplies	Deductible, then 20%	Deductible, then 20%	Deductible, then 25%	Deductible, then 25%	Deductible, then 30%	Deductible, then 30%	Deductible, then 30%	Deductible, then 30%
Home Health Care	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%
X-ray, Lab, and Diagnostics including MRI, CT, and PET scans	Deductible, then 20%	Deductible, then 50%	Deductible, then 25%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%	Deductible, then 30%	Deductible, then 50%

Notes: The boxed areas of the grid are components of each plan most often used by members when choosing a plan option, but are not all inclusive. You can refer to the Summary of Benefits and Coverage (SBC) for more information. KEHP has made every attempt to ensure the accuracy of the benefits outlined in this Benefits Grid. If an error has occurred, the benefits outlined in the 2025 Summary Plan Descriptions (SPDs) and Medical Benefit Booklets will determine how benefits are paid. Benefits are subject to the terms, conditions, limitations, and exclusions set forth in the SPDs.

• Co-pays do not accumulate toward the deductible, but they do accumulate toward the applicable maximum out-of-pocket. Once your maximum out-of-pocket is met, you do not have to pay any more co-pays.

- Certain drugs to treat diabetes, COPD, asthma, and hypertension are subject to reduced co-pays and co-insurance with no Deductibles. A 90-day supply of maintenance drugs may be subject to lower co-pays and co-insurance. Select preventive/maintenance drugs bypass the deductible on the CDHPs. Claims are processed based on provider billing type, which may include separate charges from a lab performing services outside of the doctor's office visit.

*The HDHP has a non-embedded deductible which means all family members share a deductible and out-of-pocket (OOP) maximum, regardless of the number of family members. The entire deductible must be met before any one family member receives benefits. The entire OOP must be met before the family has satisfied the OOP maximum.