kp.org/feds I can choose my doctor Ohio Region Federal Employees and Annuitants 2013 Rates and Benefits

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1 Ohio Reion Federal Employees and Annuitants 013 Rates and Benefits I can choose my doctor Not a member yet? Chat live with a representative at kp.or/feds or call toll free , Monday Friday, 8 a.m. 5 p.m., for more information. kp.or/feds Statements above related to Kaiser Permanente physicians and services only.

2 A reat choice for ood health Kaiser Permanente is uniquely desined to ive you information and support to help you live well, with everythin workin conveniently toether. your choice of top doctors You et your choice of Kaiser Permanente doctors so you can select the personal physician who s riht for you. personalized care Your Kaiser Permanente care team works with you, supported by your secure electronic health record which connects them to your up-to-date health info like lab test results, medications, and preventive screenins that are due. everythin under one roof Many of our locations include pharmacy, lab, and X-ray services, so you can do more and drive less. lots of healthy extras Stay at your best with healthy resources like farmers markets and wellness classes, some of which are free. kp.or/feds easy online access, anytime Use your computer, smartphone, or mobile device to your doctor s office, schedule routine appointments, view most lab test results, refill most prescriptions, and more. 1 quality care For the entire Ohio reion, Kaiser Permanente s Clinical Quality Score is the hihest in the market. 1 Available when you receive care at Kaiser Permanente facilities. Hewitt Health Value Initiative Benchmarkin Study Kaiser Foundation Health Plan, Inc., Aon Hewitt, March, 01. A full copy of the report is available upon request.

3 Better Informed. Better Toether. Makin smart decisions whether you re choosin a health plan for your family or dealin with a health condition can be easier than you think. All you need is a partner to ive you the riht information and support. Take a look at everythin you et with your membership, and you ll aree that Kaiser Permanente is the best choice for your health. A better way to et and stay healthy... Coordinated care...3 Online access anytime, anywhere...4 Convenient classes, resources, and more...5 Federal Employees Health Benefits (FEHB) Prorams...6 Kaiser Permanente Medicare Plus (Cost) for Federal Members...7 Your dental, vision, and travel benefits...8 How to enroll...9 Your benefits summary for Our locations...1 Prefer to see this information online? Go to kp.or/feds. Already a member? If you re currently a member and have questions, please call , Monday throuh Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. For TTY, please call

4 A better way to et and stay healthy Be better informed and take an active role in your health. You and your family et what you need to live well, and we work toether with you to help you make better choices every step of the way. What you need, when you need it Personalized care Everythin under one roof We make it simple for you to et care: easy-to-schedule appointments* access to your doctor s office* same-day and Saturday services at many locations 4-hour telephone health advice from reistered nurses recent medical information and most test results online * convenient locations urent and emerency care coverae anywhere in the world ** Your doctors, nurses, and specialists take the time to know you and your health needs. Supported by your secure electronic health record, your entire Kaiser Permanente care team is up to speed and ready to take care of you. Havin a team that s informed and focused on you can lead to quicker, better dianoses and treatments. * Available when you receive care at Kaiser Permanente facilities. Most of our locations conveniently offer multiple services under one roof. You can see your doctor, et lab services and X-rays, and fill prescriptions all at the same place. That can help you save time and avoid drivin all over town. For prescription refills, you can even order online and have most mailed to your home with free shippin. * ** This is a summary of the features of the Kaiser Permanente health plan. Before makin a final decision, please read the Plan s Federal brochure (RI ). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. See how Kaiser Permanente has helped members at kp.or/carestories. Your electronic health record brins it all toether Our innovative electronic health record system is securely linked to every Kaiser Permanente facility in Northeast Ohio, so you et coordinated care wherever you o. Your doctor s office * Your electronic health record is updated with each visit, whether you see your personal physician or another Kaiser Permanente doctor. From department to department and facility to facility, your record oes where you o. Pharmacy, lab, and X-ray If your Kaiser Permanente doctor prescribes you medications or orders lab tests, there s no paperwork to take with you. Just visit any of our medical offices, and the pharmacist or technician will pull up your doctor s orders.

5 Coordinated care Get coordinated care from doctors, nurses, and specialists who focus on you and your health. Your Kaiser Permanente care team works toether, sharin best practices and arranin any specialty care you may need. This combination of teamwork and expertise helps make our doctors better informed, so they can provide care for your needs. Your choice of doctors You choose your own Kaiser Permanente primary care physician (PCP). He or she will provide or coordinate all of your medical services, and will serve as the captain of your health care team. You can chane doctors at any time, and even choose different doctors for different family members. To find the Kaiser Permanente doctor who s riht for you, just o online to view our doctor profiles or ive us a call. Specialists ready to care for you You also have access to trained specialists. They re ready to help dianose and treat most conditions that miht come up. Our doctors and specialists work toether, makin referrals easier. And you don t even need a referral for certain specialty departments and services, includin Ob/Gyn, Behavioral Health, and Chemical Dependency Services. A focus on you and your family Our care model reduces the burden of administrative hassles, insurance claim forms, and other paperwork for our doctors, nurses, and specialists. This leaves them more time to focus on what they do best deliver care that s riht for you. Learn more about the doctors available in your area at kp.or/doctorsandlocations. Specialty care If your doctor refers you to a specialty department within one of our medical facilities, you ll receive a call. When you come in, your specialist will have your health information riht at his or her finertips. At home or on the o My Health Manaer on kp.or is your personal link to your electronic health record. This set of online tools helps you stay connected and informed about your health. 3

6 Online access anytime, anywhere Plu into your health with a variety of online and mobile tools that help you et the information you want, when you want it. Whether you re on the o or just takin advantae of a quiet moment at home, we ve ot you covered. It s easy to stay connected As a member reistered on kp.or, you have secure, 4-hour access to My Health Manaer. This online resource offers convenient tools for manain your care. * your doctor s office. View most lab test results as soon as they re available. Refill most prescriptions. Schedule or cancel routine appointments. Help take care of a family member, like a child or parent, usin these features and more. * Available when you receive care at Kaiser Permanente facilities. A website full of healthy ideas Get informed and inspired on our award-winnin website, kp.or. Take chare of your health anytime, anywhere, with online articles, wellness topics, and health calculators. And find new ways to live well with recipes from world-class chefs, music channels, podcasts, videos, and more. Good health on the o Our mobile apps make it easy to manae your health no matter where you are at home, at work, and when you re on the o. Just download our free apps for the iphone, ipad, or ipod touch from the App Store SM, or for Android devices from Goole Play. Apple, iphone, ipad, and ipod touch are trademarks of Apple, Inc., reistered in the U.S. and other countries. App Store is a service mark of Apple, Inc. Android is a trademark of Goole, Inc. For a uided tour of My Health Manaer, visit kp.or/experience. Top reasons to join Kaiser Permanente Better care You et care backed by innovative technoloy. Your care team can securely access your up-to-date health information and help you et care that s riht for you. Skilled doctors You et trained Kaiser Permanente doctors who aren t overburdened with insurance paperwork. Their focus is workin toether with you to deliver the care you need. 4

7 Convenient classes, resources, and more Fit wellness into your schedule, no matter how busy you are. We ive you lots of healthy extras that can help you stay informed about ways to live healthier mind, body, and spirit. And we ll work toether with you to provide the extra motivation you need to et started, stick with it, and maybe even cross a finish line. Learn somethin new Fresh food, better health Maximize your well-bein With the many health classes offered at our facilities, there s somethin for everyone. Try classes on stress manaement, eatin well, childbirth preparation, specific health conditions, and much more. Classes vary by location and some may require a fee. Visit kp.or/ classes to find a class near you. * Eatin well is easier when you brin home fresh food from our farmers markets. They re conveniently located at some of our facilities, so you can pick up some healthy fruits and veies after your visit. * These benefits are neither offered nor uaranteed under contract with the FEHB Proram, but are made available to all enrollees and family members who become members of the Kaiser Permanente plan. ** This is a summary of the features of the Kaiser Permanente health plan. Before makin a final decision, please read the Plan s Federal brochure (RI ). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. Our personalized online wellness prorams can help you stop smokin, lose weiht, stay active, reduce stress, sleep better, and more. * Tobacco cessation prorams and certain drus are available to you without a copayment. ** Or download the free Every Body Walk! mobile app for your smartphone or mobile device. It s a fun, interactive tool to help you create and maintain a daily walkin routine. Find tools, tips, and information for livin well at kp.or/livehealthy. Better access You et information and tools that make it easy for you to et and stay healthy includin easy-to-schedule appointments, access to your doctor, telephone health advice, and helpful online tools. Better visits You et the convenience of bein able to take care of multiple services in one trip, with virtually no paperwork. At all locations, your doctor, lab services, and pharmacy are all toether in one place. Watch members share why they chose Kaiser Permanente at kp.or/thrive. 5

8 Federal Employees Health Benefits (FEHB) Prorams As a Federal employee, you can choose between two Kaiser Permanente traditional HMO plan options. Both offer a wide rane of care and support to help you stay healthy and et the most out of life. They re desined to make it easy for you to know what to expect and et care for your needs. Kaiser Permanente FEHB Hih Option If you expect to receive care often, this option may be riht for you. You ll pay hiher premiums but lower copays for most health care services and prescription drus. Kaiser Permanente FEHB Standard Option If you and your family are in ood overall health, this miht be the riht option for you. You ll pay lower premiums but hiher copays for most services and prescriptions. The easier, the better simple copays for most covered services, includin office visits and prescriptions no paperwork to fill out or bills for the services you receive no deductibles to keep track of no referrals for certain specialties, like optometry and obstetrics-ynecoloy For help decidin which health plan option best fits your needs, visit kp.or/feds and click on Choose a Health Plan. 6

9 Kaiser Permanente Medicare Plus (Cost) for Federal Members If you re enrolled in Medicare Parts A and B (or Part B only), Kaiser Permanente Medicare Plus for Federal Members may be riht for you. Your FEHB premiums stay the same when you enroll in this plan, but you ll have lower copays for most services and better benefits. And you don t need to suspend your FEHB coverae to enroll. Maximize your benefits More is more New for 013! With Medicare Plus for Federal Members, you ll enjoy all the benefits of Oriinal Medicare, plus all the benefits of your FEHB proram, without any increase in your FEHB premiums. Review the benefits chart in this brochure for details about the lower copays and the extra benefits you receive as a member of Medicare Plus for Federal Members. Give us a call: For details about benefits, copays, limitations, and services, please call , 8 a.m. to 8 p.m., seven days a week. For TTY for the hearin/ speech impaired, call 711. One of our representatives will be happy to help. Reduced copays for most office visits, inpatient services, emerency services and prescription drus Additional coverae for hearin aids ($500 allowance per ear every 36 months) Membership in SilverSneakers Fitness Proram at no additional chare The Healthways SilverSneakers Fitness Proram can help you stay fit, have fun, and make friends throuh physical activity, health education and social events. SilverSneakers members have access to more than 11,000 fitness locations across the country, where on-site staff is available to help you meet your personal wellness oals. Fitness locations for women only are also available in certain areas. Visit silversneakers.com to find your closest location and et started. With Medicare Plus for Federal Members, your benefits are subject to Medicare rules and you may have to receive care from different plan providers than with your FEHB coverae. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premiums, and copayments/coinsurance may chane on January 1 of each year, and for roup members, at other times in accord with your roup s contract with us. To join a Kaiser Permanente Medicare health plan, you must reside in the Kaiser Permanente Medicare Plus service area in which you enroll. You must pay the Medicare Part B premium to join a Kaiser Permanente Medicare health plan. Kaiser Permanente is a Medicare-approved Cost plan. 7

10 Your dental, vision, and travel benefits Whichever option you choose, your Kaiser Permanente health plan comes with dental, vision, and travel benefits.* Dental benefits Vision benefits Travel benefits Whether you choose the Hih Option or the Standard Option, you ll have coverae for annual exams and cleanins throuh Delta Dental. To locate a Delta Dental dentist, please visit or call For more information about your dental benefits, see the benefit chart on paes 10 and 11. You can also visit kp.or/feds or return the reply card in the back of this brochure. Details about your dental benefits are included in the Federal Employees Health Benefits brochure (RI ). VSP Vision Care is our provider network for routine eye exams (eye refractions) and hardware allowances. To locate a provider, call VSP at or visit Once you ve found an optometrist, simply call that doctor to make an appointment. Let them know you have VSP and provide your Kaiser Permanente medical record number (MRN) located on your ID Card. For more information about your benefits, see the benefit chart on paes 10 and 11. You can also visit kp.or/feds or return the reply card in the back of this brochure. Details about your vision benefits are included in the Federal Employees Health Benefits brochure (RI ). * These benefits are neither offered nor uaranteed under contract with the FEHB Proram, but are made available to all enrollees and their family members who are members of Kaiser Permanente. Your travel benefits are in addition to the emerency benefits available to you within or outside your service area. When you re temporarily outside your home service area by more than 100 miles and outside any other Kaiser Permanente service area, you re covered (up to $100 per calendar year) for the followin: outpatient follow-up care to complete a course of treatment after a covered emerency (for example, to remove stitches or a cast). outpatient continuin care for covered services related to conditions dianosed and treated within the previous 1 months by a Kaiser Permanente provider or affiliated provider (like dialysis or prescription dru monitorin). Kaiser Permanente international travel clinic If you re plannin a trip abroad, the travel clinic can advise you on any health concerns you may have reardin your destination(s) and help you decide which immunizations you may need. Please call approximately eiht weeks before your trip. Call , Monday throuh Friday, 10 a.m. to 7 p.m. 8

11 How to enroll Becomin a member is easy. Just follow the three simple steps below. The information in this brochure can help you pick the riht plan, and you may be able to enroll online or by phone. 1. Choose the option that meets your needs Brief descriptions of your plan options (Hih and Standard) are on pae 6. If you re eliible for Medicare, or will be soon, take a look at additional details on pae 7.. Select the type of coverae you want If you need coverae only for yourself, choose self. If you want coverae for yourself and a spouse, child, or other dependents, choose self and family. Then note the enrollment code for your choice. 3. Enroll in Kaiser Permanente Employees and annuitants of participatin aencies may be able to enroll online. Visit opm. ov/insure/health/enrollment or contact your personnel office for information. Annuitants may call the Retirement Information Center at or (TTY for the hearin/speech impaired). 1 Your rates for 013 Non-Postal Premium Postal Premium Biweekly Share Monthly Share Biweekly Share Hih Option Standard Option Enrollment Code Gov t You Gov t You Cateory 1 Your Share Cateory Your Share Self Only 641 $ $119.5 $ $58.37 $98.05 $ Self + Family 64 $44.95 $88.4 $90.73 $64.5 $41.0 $5.83 Self Only 644 $160.9 $53.43 $ $ $35.6 $40.07 Self + Family 645 $ $1.89 $ $66.7 $81.11 $ To sin up, fill out a Health Benefits Reistration Form (Standard Form 809) from your personnel office indicatin the enrollment you want. The enrollment codes for Kaiser Permanente Health Plan are: Hih Option Self Only: 641, Hih Option Self and Family: 64, Standard Option Self Only: 644, and Standard Option Self and Family: 645. The form must then be returned to your personnel office before the December 10, 01, deadline. Your Kaiser Permanente coverae will bein the first pay period in January 013. If you are a retired Federal employee and need forms, contact the Office of Personnel Manaement at P.O. Box 45, Boyers, PA You can also retire@opm.ov or visit the website at opm.ov/retire. These rates do not apply to all enrollees. If you are in a special enrollment cateory, please refer to your special FEHB Guide or contact the aency that maintains your health benefits enrollment. 9

12 Your benefits summary for 013 Your benefits summary for 013 Kaiser Permanente Kaiser Permanente Medicare Plus for Federal Members* Services Hih Option Standard Option Hih Option Standard Option Deductible None None None None Out-of-Pocket Maximum (Sinle/Family) $,000/$6,000 $,000/$6,000 $,000/$6,000 $,000/$6,000 Office Visits Primary Care Physician $0 copay $30 copay $5 copay $15 copay Office Visits Specialist $0 copay $40 copay $5 copay $15 copay Preventive Adult Physical primary care exam Nothin Nothin Nothin Nothin Preventive Well Child Care primary care exam Nothin Nothin Nothin Nothin Preventive Immunizations Nothin Nothin Nothin Nothin Outpatient surery $0 per surery $50 per surery $5 per surery $50 per surery Urent Care Office Visits $0 per visit $45 per visit $5 per visit $35 per visit Emerency Services provided at a plan or non-plan facility Copayment waived if admitted to the hospital $75 per visit $150 per visit $50 per visit $100 per visit Ambulance Services $50 per trip $100 per trip $50 per trip $100 per trip Inpatient Services $50 per admission $500 per admission $00 per benefit period $50 per benefit period Laboratory and dianostic testin, X-rays Includes CT scans/mri, PET scans and nuclear medicine Nothin Nothin Nothin Nothin Prescription Drus 1 Covered medications and supplies prescribed by a licensed health care professional and obtained from a Plan pharmacy or throuh our Direct Mail Pharmacy. Up to a 31-day supply, or a 6-day supply sent to your home throuh our direct mail service, for one copayment. $10 eneric/ $30 brand-name $15 eneric/ $40 brand-name $5 eneric/ $10 brand-name Durable Medical Equipment (DME) 0% 0% 0% 0% Hearin aids Vision exams throuh VSP providers. Vision Care Allowance throuh VSP providers Fitness Dental, 3 throuh Delta Dental providers. To locate a provider, please visit vsp.com/advantae or call To locate a Delta Dental dentist, please visit deltadentaloh.com or call Member pays all chares in excess of $1,000 for each hearin impaired ear every 36 months. Covered only for children throuh ae 17. $10 eneric/ $0 brand-name Member pays all chares in excess of $500 for each hearin impaired ear every 36 months. $0 copay $40 copay $5 copay $15 copay The Plan provides an allowance of up to $100 every 4 months towards the purchase of eyelass lenses, frames, or contact lenses when prescribed by a Plan physician or Plan optometrist and purchased at Plan provider locations. Discounted rates on fitness club memberships throuh ChooseHealthy. Visit choosehealthy.com or call (toll free) for more information.,4 In addition to ChooseHealthy,4, includes Healthways SilverSneakers Fitness Proram with access to more than 11,000 fitness locations across the country. Visit silversneakers.com to find your closest location. For Class I Benefits (Dianostic and Preventive Services, Emerency Palliative Treatment, and X-rays), the Plan pays 70% and you pay 30%. For Class II Benefits (Oral Surery Services for simple extractions, includin preoperative and postoperative care, and Minor Restorative Services used to repair teeth damaed by disease or injury (for example, amalam and resin fillins), the Plan pays 50% and you pay 50%. Benefits for oral examinations, prophylaxes and fluoride treatment are payable twice per calendar year. Benefits for bitewin X-rays are payable once per calendar year. Maximum Payment: $750 per person total per benefit year on Class I and Class II Benefits. Deductible: None. 10 This is a summary of the features of the Kaiser Foundation Health Plan of Ohio, includin the Kaiser Permanente Medicare Plus for Federal Members plans. Before makin a final decision, please read the Plan s Federal brochure, RI All benefits are subject to the definitions, limitations, and exclusions set forth in the Plan s Federal brochure. 1 If you request a brand name dru in place of a eneric dru prescribed by your doctor, you may be required to pay full chares. These benefits are neither offered nor uaranteed under contract with the FEHB Proram, but are made available to all enrollees and family members who become members of the Kaiser Foundation Health Plan of Ohio Hih and Standard option. 3 This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental Care Certificate will provide you with additional information about your Delta Dental plan, includin information about plan exclusions and limitations. In the event that you seek treatment from a dentist that does not participate in any of Delta Dental s prorams, you may be responsible for more than the percentae indicated. 4 ChooseHealthy is a federally reistered trademark of American Specialty Health Incorporated (ASH). ChooseHealthy is provided by American Specialty Health Networks, Inc. (ASH Networks) and Healthyroads, Inc. It is a subsidiary of ASH. Please note that this is a discount proram; it is not insurance. You can access services from any ASH Networks contracted provider; referral from a primary care physician is not required. You re responsible for payin the discounted fee directly to the contracted provider. * Please see pae 7 for important information and details that apply to the Kaiser Permanente Medicare Plus for Federal Members plans. 11

13 Our locations With medical offices and hospitals close to where you live, we re helpin to make Northeast Ohio a healthier place to be. To find a location near you, visit kp.or/doctorsandlocations or download our free Kaiser Permanente app for your smartphone or mobile device. Use our location finder to search by ZIP code or keyword. Kaiser Permanente Ohio Service Area Kaiser Foundation Health Plan of Ohio North Point Tower Suite Lakeside Avenue Cleveland, Ohio Affiliated Hospitals Kaiser Permanente Medical Offices Kaiser Permanente Medical Office/ Emerency Services The Kaiser Permanente service area consists of Cuyahoa, Geaua, Lake, Lorain, Medina, Portae, Stark, Summit, and Wayne counties. Kaiser Permanente Medical Facilities 1 Avon Medical Offices Avon Bedford Medical Offices Bedford 3 Chapel Hill Medical Offices Akron 4 Cleveland Heihts Medical Center Cleveland Heihts 5 Concord Medical Offices Concord 6 Fairlawn Medical Offices Fairlawn 7 Kent Medical Offices Kent 8 Medina Medical Offices Medina 9 Mentor Medical Offices Mentor 10 North Canton Medical Offices North Canton 11 Parma Medical Center Parma 1 Rocky River Medical Offices Rocky River 13 Stronsville Medical Offices Stronsville 14 Twinsbur Medical Offices Twinsbur 15 Willouhby Medical Offices Willouhby 10 1 Lorain 5 Affiliated Hospitals (specific services may vary) 1 80 LAKE Medina 16 Akron General Medical Center Akron 71 8 Wayne 17 The Cleveland Clinic Foundation Cleveland 18 CCF Children s Hospital for Rehabilitation Cleveland 19 Children s Hospital Medical Center of Akron Akron 0 Edwin Shaw Rehabilitation Institute Cuyahoa Falls 1 EMH Reional Medical Center Elyria Fairview General Hospital (Obstetrical Referrals only) Cleveland 3 Hillcrest Hospital (Obstetrical Referrals only) Mayfield Heihts 4 LakeWest Medical Center Willouhby For more information on our service area, please call Customer Relations, Monday Thursday, 8:15 a.m. 5 p.m. and Friday, 9 a.m. 5 p.m. at (TTY ) E RIE Cuyahoa Summit Lake Stark 5 Lodi Community Hospital Lodi 6 Marymount Hospital Garfield Heihts 7 Medina General Hospital Medina 8 Mercy Medical Center Canton Geaua 9 MetroHealth Medical Center Cleveland Portae 30 Parma Community General Hospital Parma 31 Robinson Memorial Hospital Ravenna 3 TriPoint Medical Center Concord 33 Windsor Laurelwood Center for Behavioral Medicine Willouhby Z Kaiser Foundation Health Plan of Ohio 76 1

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15 A website just for you At kp.or/feds you ll find your Kaiser Permanente 013 enrollment materials, includin the Federal Employees Health Benefits brochure (RI ). You can also connect to our facility and physician directories and learn more about our services. Notice of Summary of Benefits and Coverae (SBC): Availability of Summary Health Information The Federal Employees Health Benefits (FEHB) Proram offers numerous health benefits plans and coverae options. Choosin a health plan and coverae option is an important decision. To help you make an informed choice, each FEHB plan makes available a Summary of Benefits and Coverae (SBC) about each of its health coverae options, online and in paper. The SBC summarizes important information in a standard format to help you compare plans and options. This plan s SBC is available on the internet at: kp.or/feds. A paper copy is also available, free of chare, by callin toll free , Monday throuh Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. For TTY, please call To find out more information about plans available under the FEHB Proram, includin SBCs for other FEHB plans, please visit Any questions? If you d like more information about the health coverae available throuh the Federal Employees Health Benefits Proram, includin the FEHB brochure (RI ), simply return the reply card attached. Fill out your information and choose the materials you d like to receive. Tear off the card and fold it with your information inside. Seal the card and drop it in the mail. Postae is free. Kaiser Foundation Health Plan of Ohio 1001 Lakeside Ave, Ste 100 Cleveland, OH kp.or/feds Please recycle. This material was produced from eco-responsible resources. Member and Marketin Communications Z0764 September 01