for additional information related to chronic disease management. See Hospital - Inpatient and Outpatient for outpatient hospital medical and surgical services, including ambulatory surgical centers. Plastic and Reconstructive Surgery Plastic and reconstructive services: Hospital - Inpatient: After Deductible, Enrollee • Correction of a congenital disease or congenital anomaly. pays 10% Plan Coinsurance • Correction of a Medical Condition following an injury or resulting from surgery which has produced a major effect on the Enrollee’s appearance, when in the opinion of Hospital - Outpatient: After Deductible, Enrollee KFHPWA’s medical director such services can pays 10% Plan Coinsurance reasonably be expected to correct the condition. • Reconstructive surgery and associated procedures, including internal breast prostheses, following a Outpatient Services: After Deductible, Enrollee mastectomy, regardless of when the mastectomy was pays 10% Plan Coinsurance performed. Enrollees are covered for all stages of reconstruction on the non-diseased breast produce a symmetrical appearance. Complications of covered mastectomy services, including lymphedemas, are covered. Plastic and reconstructive surgery requires Preauthorization. Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery; cosmetic surgery; complications of non-Covered Services Podiatry Medically Necessary foot care. After Deductible, Enrollee pays 10% Plan Coinsurance Routine foot care covered when such care is directly related to the treatment of diabetes and, when approved by KFHPWA’s medical director, other clinical conditions that affect sensation and circulation to the feet. Exclusions: All other routine foot care Preventive Services Preventive services in accordance with the well care schedule No charge; Enrollee pays nothing established by KFHPWA may require Preauthorization. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. Screening and tests with A and B recommendations by the PEBB HMOHSA 2024 36