Limited to a combined total of 60 inpatient days and 60 outpatient visits per calendar year for all Rehabilitation, Habilitative care, cardiac and pulmonary rehabilitation services. Exclusions: Specialty treatment programs; inpatient Residential Treatment services; specialty rehabilitation programs including “behavior modification programs”; recreational, life-enhancing, relaxation or palliative therapy; implementation of home maintenance programs Reproductive Health Medically Necessary medical and surgical services for Hospital - Inpatient: No charge; Enrollee pays reproductive health, including consultations, examinations, nothing procedures and devices, including device insertion and removal. Hospital - Outpatient: No charge; Enrollee pays nothing See Maternity and Pregnancy for pregnancy care and termination of pregnancy 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 No charge; Enrollee pays nothing (including over-the-counter) contraceptive drugs, devices and products. Condoms are limited to 120 per 90-day supply, additional condoms available upon request. 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. Enrollee pays $20 Copayment for primary care provider office visits After Deductible, Enrollee pays 15% Plan PEBB_SCA_2024 40