COVERED SERVICE BENEFIT 13. Hearing Instruments 100% subject to $30 Copayment after Visits for hearing instrument Services, such as assessment, fitting, meeting $1,600 of the self-only adjustment, and auditory training Deductible or $3,200 of the individual Family Member or Family Deductible (whichever applies) per exam Hearing instruments 100% after meeting $1,600 of the self- $3,000 allowance for each hearing instrument per ear every 36 only Deductible or $3,200 of the months individual Family Member or Family Deductible (whichever applies) 100% subject to 20% Coinsurance after meeting $1,600 of the self-only Ear molds Deductible or $3,200 of the individual Family Member or Family Deductible (whichever applies) 14. Home Health Services (up to 130 visits per Year) 100% after Deductible subject to 15% Coinsurance after Deductible 15. Hospice Services (including respite care) Hospice Services (respite care is limited to no more than five 100% after Deductible consecutive days in a three-month period of hospice care) 16. Hospital Services Inpatient hospital Services 100% subject to 15% Coinsurance after Deductible Inpatient professional Services 100% subject to 15% Coinsurance after Deductible Outpatient hospital Services 100% subject to 15% Coinsurance after Deductible Outpatient surgery professional Services 100% subject to 15% Coinsurance after Deductible 100% after meeting $1,600 of the self- 17. Interrupted Pregnancy Surgery only Deductible or $3,200 of the individual Family Member or Family Deductible (whichever applies) 18. Kaiser Permanente at Home™ Medical Services in your home as an alternative to receiving acute 100% after Deductible care in a hospital 19. Massage Therapy (up to 12 visits per Year) 100% subject to $25 Copayment after Deductible per visit 20. Medical Foods and Formula 100% subject to 20% Coinsurance after Deductible 21. Mental Health Services Inpatient and residential 100% subject to 15% Coinsurance after Deductible 100% subject to $20 Copayment after Outpatient and intensive outpatient Services Deductible per office visit or per day (100% after Deductible for Members age 17 years and younger) EWCLGHDHP1983ACT0124 3 WAPEBB-CD-ACT