Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved; care rendered primarily for the convenience of the Enrollee; care rendered on a non-acute, asymptomatic basis; charges for any other services that do not meet KFHPWA clinical criteria as Medically Necessary Massage Therapy Visits with licensed massage therapists to restore function After Deductible, Enrollee pays $30 specialty care immediately following illness, injury or surgery, limited to a provider services Copayment combined total of 24 visits per calendar year without Preauthorization. Outpatient services require a prescription or order from a physician that reflects a written plan of care to restore function. Exclusions: Recreational; life-enhancing, relaxation or services designed to relieve or soothe symptoms of a disease or disorder without effecting a cure (palliative therapy); massage therapists preventive services; any services not within the scope of the practitioner’s licensure Maternity and Pregnancy Pregnancy care and services, including care for complications Hospital - Inpatient: After Deductible, Enrollee of pregnancy, in utero treatment for the fetus, prenatal testing pays $150 Copayment per day up to $750 per for the detection of congenital and heritable disorders when admission Medically Necessary and prenatal and postpartum care are covered for all Enrollees including eligible Dependents. Hospital - Outpatient: After Deductible, Enrollee Preventive services related to preconception, prenatal and pays $150 Copayment postpartum care are covered as Preventive Services including breastfeeding support, supplies and counseling for each birth Outpatient Services: After Deductible, Enrollee when Medically Necessary as determined by KFHPWA’s pays $15 primary care provider services Copayment medical director and in accordance with Board of Health or $30 specialty care provider services Copayment standards for screening and diagnostic tests during pregnancy. Delivery and associated Hospital Care, including home births and birthing centers. Home births are considered outpatient services. Enrollees must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission, or as soon thereafter as medically possible. The Enrollee’s provider, in consultation with the Enrollee, will determine the Enrollee’s length of inpatient stay following delivery. Donor human milk will be covered during the inpatient hospital stay when Medically Necessary, provided through a milk bank and ordered by a licensed Provider or board- certified lactation consultant. Termination of pregnancy. Hospital - Inpatient: Enrollee pays nothing Non-Emergency inpatient hospital services require Hospital - Outpatient: Enrollee pays nothing Preauthorization. PEBB_CA_2024 29