Primary Care Participating Providers ...................................................................................................................... 31 Women’s health Care Services ................................................................................................................................. 31 Referrals ....................................................................................................................................................................... 31 Referrals to Participating Providers and Participating Facilities ................................................................... 31 Referrals to Non-Participating Providers and Non-Participating Facilities ................................................ 32 Prior and Concurrent Authorization and Utilization Review .............................................................................. 32 Individual Case Management ............................................................................................................................. 34 Home Health Care Alternative to Hospitalization ......................................................................................... 34 Participating Providers and Participating Facilities Contracts ............................................................................. 34 Provider Whose Contract Terminates..................................................................................................................... 34 Receiving Care in Another Kaiser Foundation Health Plan Service Area ......................................................... 35 Post Service Claims – Services Already Received ..................................................... 35 Emergency, Post-Stabilization, and Urgent Care ........................................................ 36 Emergency Services ................................................................................................................................................... 36 Post-Stabilization Care .............................................................................................................................................. 37 Urgent Care ................................................................................................................................................................. 38 Inside our Service Area ....................................................................................................................................... 38 Outside our Service Area ................................................................................................................................... 38 What You Pay ................................................................................................................. 38 Deductible ................................................................................................................................................................... 38 Increasing the Deductible .................................................................................................................................. 38 Changes to Your Family ..................................................................................................................................... 38 Copayments and Coinsurance .................................................................................................................................. 39 Out-of-Pocket Maximum .......................................................................................................................................... 39 Benefit Details ................................................................................................................ 39 1. Accidental Injury to Teeth .................................................................................................................................... 40 2. Administered Medications .................................................................................................................................... 40 3. Acupuncture Services ............................................................................................................................................ 40 4. Ambulance Services ............................................................................................................................................... 41 5. Bariatric Surgery and Weight Control and Obesity Treatment ....................................................................... 41 6. Services Provided in Connection with Clinical Trials ....................................................................................... 42 7. Diabetic Education ................................................................................................................................................ 43 8. Diagnostic Testing, Laboratory, Mammograms and X-ray ............................................................................. 43 9. Dialysis—Outpatient ............................................................................................................................................. 43 10. Durable Medical Equipment (DME) and External Prosthetic Devices and Orthotic Devices ............... 43 11. Emergency Services ............................................................................................................................................. 46 12. Habilitative Services ............................................................................................................................................. 46 13. Hearing Instruments ............................................................................................................................................ 47 14. Home Health Services ......................................................................................................................................... 47 EWCLGHDHP01983ACT0124 WAPEBB-CD-ACT