determined by the Member’s PCP or Participating Provider, in consultation with the mother. Our policy complies with the federal Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA). Use of birthing centers for delivery must be preauthorized as described in the “Prior and Concurrent Authorization and Utilization Review” section of this EOC. Medically Necessary Services furnished in connection with childbirth at your home are covered when provided by a Participating Provider, subject to the specialty care office visit Cost Share. Hospitalization for newborn children for other than routine newborn care will be covered subject to the inpatient hospital Cost Share for the first 21 days from the date of birth, provided the mother is covered by this Plan. Benefits for professional and other Services for necessary follow-up care for newborns are provided subject to any applicable Cost Share amounts for the first 21 days from the date of birth provided the mother is covered by this Plan. Benefits for Services received by the newborn beyond the initial 21 days are subject to the eligibility requirements of this Plan, including submission of any PEBB Program application for coverage, and payment of any required premium. If premium is not due, the application requirement is waived; however, please notify the PEBB Program or your Employing Agency of the birth so that your records may be updated. Services related to voluntary and involuntary termination of pregnancy on an outpatient basis are covered. Inpatient hospital Services related to voluntary and involuntary termination of pregnancy are covered, subject to the inpatient hospital Cost Share. Obstetrics, Maternity and Newborn Care Exclusions  Home birth Services provided by family or Non-Participating Providers. 24. Office Visits Services provided by the Member’s PCP are covered at your Primary care visit Cost Share shown in the “Benefit Summary”. Visits to a Specialist, when referred by the Member’s PCP, are covered at the Specialty care visit Cost Share shown in the “Benefit Summary”. A Urgent Care visit Cost Share applies to qualifying Urgent Care received during certain hours at designated Urgent Care facilities and Participating Medical Offices within the Service Area and from Non-Participating Providers outside the Service Area. Injections, including allergy injections, are covered when received in a nurse treatment room. Family Planning Services are covered when provided by the Member’s PCP or women’s health care Participating Provider. 25. Organ Transplants Transplant Services for bone marrow, cornea, heart, heart-lung, kidney, liver, lung, pancreas, pancreas after kidney, simultaneous kidney-pancreas, small bowel, small bowel/liver, and stem cell, including professional and Participating Facility fees for inpatient accommodation, diagnostic tests and exams, surgery and follow-up care, are covered subject to inpatient hospital Cost Share or office visit Cost Share and preauthorization requirements as described in the “Prior and Concurrent Authorization and Utilization Review” section of this EOC. See other benefits of this Plan for related Services, such as prescription drugs and outpatient laboratory and X-ray. Organ transplants are covered when preauthorized as described in the “Prior and Concurrent Authorization and Utilization Review” section of this EOC, and performed in a National Transplant Network facility. A National Transplant Network facility is a transplant facility that meets all of the following requirements:  It is licensed in the state where it operates. EWCLGDED1983ACT0124 55 WAPEBB-CL-ACT

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