ria/pdf/gender_reassignment_surgery.pdf for details. pays $150 Copayment Prescription drugs are covered the same as for any other Outpatient Services: After Deductible, Enrollee condition (see Drugs – Outpatient Prescription for coverage). pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Counseling services are covered the same as for any other condition (see Mental Health and Wellness for coverage). Non-Emergency inpatient hospital services require Preauthorization. Exclusions: Cosmetic services and surgery not related to gender affirming treatment (i.e., face lift or calf implants); complications of non-Covered Services Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered Hospital - Inpatient: After Deductible, Enrollee only when provided at KFHPWA-approved facilities. pays $150 Copayment per day up to $750 per admission Cochlear implants or Bone Anchored Hearing System (BAHS) when in accordance with KFHPWA clinical criteria. Hospital - Outpatient: After Deductible, Enrollee pays $150 Copayment Covered services for cochlear implants and BAHS include diagnostic testing, pre-implant testing, implant surgery, post- Outpatient Services: After Deductible, Enrollee implant follow-up, speech therapy, programming and pays $15 primary care provider services Copayment associated supplies (such as transmitter cable, and batteries). or $30 specialty care provider services Copayment Replacement devices and associated supplies – see Devices, Equipment and Supplies Section. Hearing aids including fitting, follow-up care and repairs. Enrollee pays nothing, limited to an Allowance of $3,000 maximum per ear during any consecutive 36- month period After Allowance: Not covered; Enrollee pays 100% of all charges Initial assessment, fitting, adjustments, auditory training and Outpatient Services: After Deductible, Enrollee ear molds as necessary to maintain optimal fit. pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Exclusions: Programs or treatments for hearing loss or hearing care associated with externally worn hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above; hearing screening tests required under Preventive Services; replacement costs of hearing aids due to loss, breakage or theft, unless at the time of such replacement the Enrollee is eligible under the benefit Allowance; replacement parts; replacement batteries; maintenance costs Home Health Care Home health care when the following criteria are met: No charge; Enrollee pays nothing • Except for patients receiving palliative care services, the Enrollee must be unable to leave home due to a health PEBB_CRCOB_2024 24