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 $150 Copayment per day up to $750 per • Correction of a Medical Condition following an injury or admission 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 $150 Copayment reasonably be expected to correct the condition. • Reconstructive surgery and associated procedures, Outpatient Services: After Deductible, Enrollee including internal breast prostheses, following a pays $15 primary care provider services Copayment mastectomy, regardless of when the mastectomy was or $30 specialty care provider services Copayment performed. Enrollees are covered for all stages of reconstruction on the non-diseased breast to 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 $15 primary care provider services Copayment or $30 specialty care Routine foot care covered when such care is directly related provider services Copayment 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 U.S. Preventive Services Task Force (USPSTF). PEBB_CA_2024 36