Medically Necessary. Our determination that the Service is all of the following: (i) medically required to prevent, diagnose or treat your condition or clinical symptoms; (ii) in accordance with generally accepted standards of medical practice; (iii) not solely for the convenience of you, your family and/or your provider; and, (iv) the most appropriate level of Service which can safely be provided to you. For purposes of this definition, “generally accepted standards of medical practice” means (a) standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community; (b) physician specialty society recommendations; (c) the view of physicians practicing in the relevant clinical area or areas within Kaiser Permanente locally or nationally; and/or (d) any other relevant factors reasonably determined by us. Unless otherwise required by law, we decide if a Service is Medically Necessary. You may appeal our decision as set forth in the “Grievances, Claims, Appeals, and External Review” section. The fact that a Participating Provider has prescribed, recommended, or approved a Service does not, in itself, make such Service Medically Necessary and, therefore, a covered Service. Medicare. A federal health insurance program for people aged 65 and older, certain people with disabilities, and those with end-stage renal disease (ESRD). Member. An employee, Continuation Coverage Enrollee, or Dependent who is eligible and enrolled under this EOC, and for whom Kaiser has received applicable premium. This EOC sometimes refers to a Member as “you” or “Enrollee.” The term Member may include the Subscriber, their Dependent, or other individual who is eligible for and enrolled under this EOC. New Episode of Care. Treatment for a new condition or diagnosis for which you have not been treated by a Participating Provider of the same licensed profession within the previous 90 days and are not currently undergoing any active treatment. Non-Participating Facility. Any of the following licensed institutions that provide Services, but which are not Participating Facilities: hospitals and other inpatient centers; ambulatory surgical or treatment centers; birthing centers; medical offices and clinics; skilled nursing facilities; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation settings. This includes any of these facilities that are owned and operated by a political subdivision or instrumentality of the state and other facilities as required by federal law and implementing regulations. Non-Participating Provider. A physician or other health care provider, facility, business, or vendor regulated under state law to provide health or health-related services or otherwise providing health care services within the scope of licensure or certification consistent with state law that does not have a written agreement with Kaiser Permanente to participate as a health care provider for this Plan. Orthotic Devices. Orthotic devices are rigid or semi-rigid external devices (other than casts) required to support or correct a defective form or function of an inoperative or malfunctioning body part or to restrict motion in a diseased or injured part of the body. Out-of-Pocket Maximum. The total amount of Copayments, Coinsurance and Deductible you will be responsible to pay in a Year, as described in the “Out-of-Pocket Maximum” section of this EOC. Participating Facility. Any facility listed as a Participating Facility in the Medical Facility Directory. Participating Facilities are subject to change. Participating Hospital. Any hospital listed as a Participating Hospital in the Medical Facility Directory. Participating Hospitals are subject to change. Participating Medical Office. Any outpatient treatment facility listed as a Participating Medical Office in the Medical Facility Directory. Participating Medical Offices are subject to change. Participating Pharmacy. A pharmacy owned and operated by Kaiser Permanente or another pharmacy that we designate that is listed as a Participating Pharmacy in the Medical Facility Directory. Participating Pharmacies are subject to change. EWCLGHDHP1983ACT0124 12 WAPEBB-CD-ACT