Exclusions: Recreational; life-enhancing, relaxation or services designed to relieve or soothe symptoms of a disease or disorder without effective 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 $500 Copayment per admission for the detection of congenital and heritable disorders when Medically Necessary and prenatal and postpartum care are Hospital - Outpatient: After Deductible, Enrollee covered for all Enrollees including eligible Dependents. pays 15% Plan Coinsurance Preventive services related to preconception, prenatal and postpartum care are covered as Preventive Services including Outpatient Services: Enrollee pays $20 Copayment breastfeeding support, supplies and counseling for each birth for primary care provider office visits when Medically Necessary as determined by KFHPWA’s medical director and in accordance with Board of Health After Deductible, Enrollee pays 15% Plan standards for screening and diagnostic tests during pregnancy. Coinsurance for specialty care provider office visits 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. Outpatient Services: Enrollee pays nothing Exclusions: Birthing tubs; genetic testing of non-Enrollees; fetal ultrasound not considered Medically Necessary Mental Health and Wellness Mental health and wellness services provided at the most Hospital - Inpatient: After Deductible, Enrollee clinically appropriate and Medically Necessary level of pays $500 Copayment per admission mental health care intervention as determined by KFHPWA’s medical director. Treatment may utilize psychiatric, Hospital - Outpatient: After Deductible, Enrollee psychological and/or psychotherapy services to achieve these pays 15% Plan Coinsurance objectives. Outpatient Services: Enrollee pays $20 Copayment Mental health and wellness services including medical for primary care provider office visits management and prescriptions are covered the same as for PEBB_SCA_2024 30