members may submit a request online at www.KP.org/wa/formulary or by contacting Member Services. Sexual Dysfunction Sexual dysfunction diagnosis and medical treatment services. After Deductible, Enrollee pays 10% Plan Coinsurance Penile prosthesis when impotence is caused by a covered After Deductible, Enrollee pays 10% Plan Medical Condition as a direct result of a covered surgery, or a Coinsurance result of an injury to the genitalia or spinal cord, and when other accepted treatment has been unsuccessful. Exclusions: Prescription drugs for treatment of sexual dysfunction; devices, equipment and supplies for the treatment of sexual dysfunction; penile prosthesis when not medically necessary; All other devices, equipment and supplies for the treatment of sexual dysfunction not specifically listed as covered Skilled Nursing Facility Skilled nursing care in a skilled nursing facility when full- After Deductible, Enrollee pays 10% Plan time skilled nursing care is necessary in the opinion of the Coinsurance attending physician, limited to a total of 150 days per calendar year. Care may include room and board; general nursing care; drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and short- term restorative occupational therapy, physical therapy and speech therapy. Skilled nursing care in a skilled nursing facility requires Preauthorization. Exclusions: Personal comfort items such as telephone and television; rest cures; domiciliary or Convalescent Care Sterilization FDA-approved female sterilization procedures, services and Hospital - Inpatient: No charge; Enrollee pays supplies. See Preventive Services for additional information. nothing Non-Emergency inpatient hospital services require Hospital - Outpatient: No charge; Enrollee pays Preauthorization. nothing Outpatient Services: No charge; Enrollee pays nothing Vasectomy. Hospital - Inpatient: After minimum Deductible, Enrollee pays nothing Non-Emergency inpatient hospital services require PEBB HMOHSA 2024 40