COVERED SERVICE BENEFIT 15. Hospice Services (including respite care) Hospice Services (respite care is limited to no more than five 100% 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 17. Interrupted Pregnancy Surgery 100% 18. Kaiser Permanente at Home™ Medical Services in your home as an alternative to receiving 100% acute care in a hospital 19. Massage Therapy (up to 12 visits per Year) 100% subject to $25 Copayment 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 $25 Copayment per Outpatient and intensive outpatient Services office visit or per day (100% for Members age 17 years and younger) 100% subject to $25 Copayment per Partial hospitalization office visit or per day (100% for Members age 17 years and younger) 22. Naturopathic Medicine Evaluation and treatment 100% subject to $25 Copayment (100% for Members age 17 years and younger) 23. Obstetrics, Maternity and Newborn Care Scheduled prenatal care visits and postpartum visits 100% Inpatient hospital Services 100% subject to 15% Coinsurance after Deductible Home birth obstetrical care and delivery 100% subject to $35 Copayment per visit 24. Office Visits 100% subject to $25 Copayment per visit Primary care visits (100% for Members age 17 years and younger) Specialty care visits 100% subject to $35 Copayment per visit Urgent Care visits 100% subject to $45 Copayment per visit Nurse treatment room visits to receive injections 100% subject to $10 Copayment per visit 25. Organ Transplants Inpatient facility Services 100% subject to 15% Coinsurance after Deductible EWCLGDED1983ACT0124 3 WAPEBB-CL-ACT