See Hospital - Inpatient and Outpatient for outpatient hospital medical and surgical services, including ambulatory surgical centers. Plastic and Reconstructive Surgery Plastic and reconstructive services: Hospital - Inpatient: After Deductible, Enrollee • Correction of a congenital disease or congenital anomaly. pays $500 Copayment per admission • Correction of a Medical Condition following an injury or resulting from surgery which has produced a major effect Hospital - Outpatient: After Deductible, Enrollee on the Enrollee’s appearance, when in the opinion of pays 15% Plan Coinsurance KFHPWA’s medical director such services can reasonably be expected to correct the condition. Outpatient Services: Enrollee pays $20 Copayment • Reconstructive surgery and associated procedures, for primary care provider office visits including internal breast prostheses, following a mastectomy, regardless of when the mastectomy was After Deductible, Enrollee pays 15% Plan performed. Enrollees are covered for all stages of Coinsurance for specialty care provider office visits reconstruction on the non-diseased breast to produce a symmetrical appearance. Complications of covered mastectomy services, including lymphedemas, are covered. Plastic and reconstructive surgery requires Preauthorization. Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery; cosmetic surgery; complications of non-Covered Services Podiatry Medically Necessary foot care. Enrollee pays $20 Copayment for primary care provider office visits Routine foot care covered when such care is directly related to the treatment of diabetes and, when approved by After Deductible, Enrollee pays 15% Plan KFHPWA’s medical director, other clinical conditions that Coinsurance for specialty care provider office visits affect sensation and circulation to the feet. Exclusions: All other routine foot care Preventive Services Preventive services in accordance with the well care schedule No charge; Enrollee pays nothing established by KFHPWA may require Preauthorization. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. Screening and tests with A and B recommendations by the U.S. Preventive Services Task Force (USPSTF). Services, tests and screening contained in the U.S. Health PEBB_SCA_2024 37