Preauthorization. Hospital - Outpatient: After minimum Deductible, Enrollee pays nothing Outpatient Services: After minimum Deductible, Enrollee pays nothing Note: Vasectomies are required to be subject to the minimum Deductible amount in order to meet state law requirements ($1,600 individual/$3,200 family). All other services are subject to the entire Annual Deductible. The minimum Deductible amount may increase as determined by federal law. Enrollees will receive notification of any changes to the minimum Deductible amount. Exclusions: Procedures and services to reverse a sterilization Substance Use Disorder Substance use disorder services including inpatient Hospital - Inpatient: After Deductible, Enrollee Residential Treatment; diagnostic evaluation and education; pays 10% Plan Coinsurance organized individual and group counseling; and/or prescription drugs unless excluded under Sections IV. or V. Outpatient Services: After Deductible, Enrollee pays 10% Plan Coinsurance Substance use disorder means a substance-related or addictive disorder listed in the most current version of the Diagnostic Group Sessions: After Deductible, Enrollee pays and Statistical Manual of Mental Disorders (DSM). For the nothing purposes of this section, the definition of Medically Necessary shall be expanded to include those services necessary to treat a substance use disorder condition that is having a clinically significant impact on an Enrollee’s emotional, social, medical and/or occupational functioning. Substance use disorder services are limited to the services rendered by a physician (licensed under RCW 18.71 and RCW 18.57), a psychologist (licensed under RCW 18.83), a substance use disorder treatment program licensed for the service being provided by the Washington State Department of Social and Health Services (pursuant to RCW 70.96A), a master’s level therapist (licensed under RCW 18.225.090), an advance practice psychiatric nurse (licensed under RCW 18.79) or, in the case of non-Washington State providers, those providers meeting equivalent licensing and certification requirements established in the state where the provider’s practice is located. The severity of symptoms designates the appropriate level of care and should be determined through a thorough assessment completed by a licensed provider who recommends treatment based on medical necessity criteria. Court-ordered substance use disorder treatment shall be covered only if determined to be Medically Necessary. PEBB HMOHSA 2024 41