Account Change Form - Kaiser Permanente For Individuals And Families Page 3

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Option 1: Choose Your Health Plan

If you indicated that you would like to change plans or add medical

KP — Bronze 60 HSA HMO 5500/40%

KP — Gold 80 HMO Copay

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coverage for a family member, please select the plan you would like.

KP — Bronze 60 HMO

K P — Gold 80 HMO

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Each family member you listed on page 2 will be moved into the

Coinsurance

KP — Bronze 60 HSA HMO

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plan you select. If you wish to enroll family members in different

KP — Platinum 90 HMO

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KP — Silver 70 HMO

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plans, please submit a separate form for each plan.

KP — Minimum Coverage

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KP — Silver 70 HMO 1500/40

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KP — Silver 70 HSA HMO 2700/15%

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Option 2: Choose Your Optional Dental Plan

You can enroll in or end adult dental coverage in the optional Dental Insurance Plan during open enrollment, annual member renewal, or a special

enrollment period. Optional adult dental coverage is available for an additional monthly charge. Our optional adult dental coverage is underwritten by

Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., and administered by Delta Dental of California, one of

the nation’s largest and most experienced dental benefits providers.

Add optional adult dental coverage.

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End optional adult dental coverage.

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60329311 California 2016