This out-of-area benefit cannot be combined with any other benefit, so we will not pay under this “Out-of-Area Coverage for Dependents” section for a Service we are covering under another section, such as:  Services covered under the “Emergency, Post-Stabilization, and Urgent Care” section; or under “Primary Care Participating Providers” in the “How to Obtain Services” section.  “Organ transplants” under “Benefit Details.”  “Receiving Care in Another Kaiser Foundation Health Plan Service Area.” 27. Outpatient Surgery Visit Services at an ambulatory surgical center (discharged within 24 hours of admission) are covered. Services must be provided at a Participating Facility and are subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser. General anesthesia Services and related facility charges in conjunction with any non-covered dental procedure performed in an ambulatory surgical center are covered if such anesthesia Services and related facility charges are Medically Necessary because the Member:  is a child under age seven, or is physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or  has a medical condition that the Member’s PCP determines would place the Member at undue risk if the dental procedure were performed in a dental office. For the purpose of this section, “general anesthesia Services” means Services to induce a state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command. Nitrous oxide analgesia is not reimbursable as general anesthesia. 28. Prescription Drugs, Insulin, and Diabetic Supplies We cover outpatient prescription drugs and supplies as described in this section. Covered drugs and supplies must be prescribed by a Participating Provider or any licensed dentist in accordance with our drug Formulary guidelines. Over-the-counter contraceptive drugs, device, and products, approved by the U.S. Food and Drug Administration (FDA), do not require a prescription in order to be covered. You must obtain drugs and supplies at a Participating Pharmacy (including our Mail-Order Pharmacy). You may obtain a first fill of a drug or supply at any Participating Pharmacy. All refills must be obtained through a pharmacy owned and operated by Kaiser Permanente (including our Mail-Order Pharmacy), or at another Participating Pharmacy that we designate for covered refills. See your Medical Facility Directory, visit kp.org/directory/nw, or contact Member Services. Covered Drugs and Supplies Items covered under this “Prescription drugs, insulin, and diabetic supplies” benefit include:  Certain preventive medications (including, but not limited to, aspirin, fluoride, liquid iron for children ages 6 to 12 months at risk for anemia, and tobacco cessation drugs) according to, and as recommended by, the USPSTF, when obtained with a prescription order.  Certain self-administered IV drugs, fluids, additives, and nutrients that require specific types of parenteral-infusion (such as IV or intraspinal-infusion) for up to a 30-day supply, including the supplies and equipment required for their administration. EWCLGDED1983ACT0124 57 WAPEBB-CL-ACT