 Prescription drugs, including injections.  Rehabilitative therapy Services such as massage (soft tissue mobilization), physical, occupational, and speech therapy Services.  Respiratory therapy.  Room and board, including a private room if Medically Necessary.  Specialized care and critical care units.  Temporomandibular joint (TMJ) surgery for the treatment of TMJ disorders subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser.  Vasectomy. Outpatient Hospital Services We cover outpatient Services for diagnosis, treatment, and preventive medicine upon payment of any applicable Cost Share shown in the “Benefit Summary” in the “Outpatient Services” section. Additional types of outpatient Services are covered as described under other headings in this “Benefits” section. Some outpatient Services may be subject to prior authorization from Company in accordance with Utilization Review criteria developed by Medical Group and approved by Company. For more information about Services that require Utilization Review, or to request a copy of the criteria for a specific condition or Service, please contact Member Services. Covered outpatient Services include but are not limited to:  Allergy testing and treatment materials.  Cardiac rehabilitative therapy visits.  Chemotherapy and radiation therapy Services.  Diagnostic Services and scope insertion procedures, such as colonoscopy, endoscopy, and laparoscopy.  Drugs, injectables, and radioactive materials used for therapeutic or diagnostic purposes, if they are administered to you in a Participating Medical Office or during home visits, subject to the drug formulary and exclusions described under the “Limited Outpatient Prescription Drugs and Supplies” section.  Emergency department visits.  Gender Affirming Treatment.  Internally implanted devices, including cochlear implants, except for internally implanted insulin pumps.  Nurse treatment room visits to receive injections, including allergy injections.  Outpatient surgery and other outpatient procedures, including interrupted pregnancy surgery performed in an outpatient setting.  Primary care visits for internal medicine, gynecology, family medicine, and pediatrics.  Rehabilitative therapy Services such as massage (soft tissue mobilization), physical, occupational, and speech therapy Services, subject to the benefit limitations shown in the “Rehabilitative Therapy Services” section of the “Benefit Summary.”  Respiratory therapy.  Routine eye exams.  Routine hearing exams.  Specialty care visits (includes home birth). EWCLGHDHP1983ACT0124 50 WAPEBB-CD-ACT