services Outpatient Services: No charge; enrollee pays nothing Reproductive health is the care necessary to support the reproductive system and the ability to reproduce. Reproductive health includes contraception, cancer and disease screenings, termination of pregnancy, maternity, prenatal and postpartum care. All methods for Medically Necessary FDA-approved generic No charge; Enrollee pays nothing (including over-the-counter) contraceptive drugs, devices and products. Condoms are limited to 120 per 90-day supply. Contraceptive drugs may be allowed up to a 12-month supply and, when available, picked up in the provider’s office. Note: Over-the-counter contraceptives can be purchased at any KFHPWA-designated pharmacy. Designated pharmacies may submit the claim. If self-payment is made at a non- KFHWA-designated pharmacy, a reimbursement claim may be made by utilizing the Member Reimbursement Drug Claim Form which can be obtained in the “Forms & Publications” section on www.kp.org/wa or by calling Member Services. To request an exception for quantity limits on condoms, members may submit a request online at www.KP.org/wa/formulary or by contacting Member Services. Sexual Dysfunction Sexual dysfunction diagnosis and medical treatment services. After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Penile prosthesis, when impotence is caused by a covered Enrollee pays 20% coinsurance medical condition, as a direct result of a covered surgery, or a result of an injury to the genitalia or spinal cord, and when other accepted treatment has been unsuccessful. Exclusions: Prescription drugs for treatment of sexual dysfunction; devices, equipment and supplies for the treatment of sexual dysfunction; penile prosthesis when not Medically Necessary; All other devices, equipment and supplies for the treatment of sexual dysfunction not specifically listed as covered Skilled Nursing Facility Skilled nursing care in a skilled nursing facility when full- After Deductible, Enrollee pays $150 Copayment per time skilled nursing care is necessary in the opinion of the day up to $750 per admission attending physician, limited to a total of 150 days per calendar year. Care may include room and board; general nursing care; drugs, biologicals, supplies and equipment ordinarily provided or arranged by a skilled nursing facility; and short- PEBB_CRCOB_2024 39