Inpatient mental health and wellness services, Residential Treatment and partial hospitalization programs must be provided at a hospital or facility that KFHPWA has approved specifically for the treatment of mental disorders. Non-Emergency inpatient hospital services, including Residential Treatment, require Preauthorization. Outpatient specialty services, including partial hospitalization programs, rTMS, ECT, and Esketamine require Preauthorization. Routine outpatient therapy and psychiatry services with contracted network providers do not require Preauthorization. Exclusions: Specialty treatment programs such as “behavior modification programs” not considered Medically Necessary; relationship counseling or phase of life problems (Z code only diagnoses);wilderness therapy; aversion therapy Naturopathy Naturopathy. After Deductible, Enrollee pays $15 primary care provider services Copayment Limited to 3 visits per medical diagnosis per calendar year without Preauthorization. Additional visits are covered with Preauthorization. Laboratory and radiology services are covered only when obtained through a Network Facility. Exclusions: Herbal supplements; nutritional supplements; any services not within the scope of the practitioner’s licensure Newborn Services Newborn services are covered the same as for any other Hospital - Inpatient: After Deductible, Enrollee condition. Any Cost Share for newborn services is separate pays $150 Copayment per day up to $750 per from that of the mother. admission Preventive services for newborns are covered under During the baby’s initial hospital stay while the birth Preventive Services. mother and baby are both confined, any applicable Deductible and Copayment for the newborn are When an Enrollee gives birth, the newborn is entitled to the waived benefits set forth in the EOC from birth through 3 weeks of age. After 3 weeks of age, no benefits are available unless the Hospital - Outpatient: After Deductible, Enrollee newborn child qualifies as a Dependent and is enrolled. See pays $150 Copayment Section VI. for enrollment information. Outpatient Services: After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Nutritional Counseling Nutritional counseling. After Deductible, Enrollee pays $15 primary care PEBB_CA_2024 31