 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).  Treatment for temporomandibular joint (TMJ) disorder.  Urgent Care visits.  Vasectomy. Dental Anesthesia—Inpatient/Outpatient General anesthesia Services and related facility charges in conjunction with any dental procedure performed in a hospital are covered subject to the applicable inpatient/outpatient facility Cost Share 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 or Participating Provider determines would place the Member at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the Member’s PCP or Participating Provider. 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. 17. Interrupted Pregnancy Surgery We cover interrupted pregnancy surgery in an inpatient or outpatient setting. 18. Kaiser Permanente at Home™ Kaiser Permanente at Home is a personalized, patient-centered program that provides care in your home (or a place of temporary or permanent residence used as your home) as an alternative to receiving acute care in a hospital. Kaiser Permanente at Home Services must be associated with an acute medical condition, such as, but not limited to, congestive heart failure, pneumonia, cellulitis or upper urinary tract infection, and are subject to prior authorization from Company in accordance with Utilization Review criteria developed by Medical Group and approved by Company. To receive Kaiser Permanente at Home Services:  You must be referred into the program by a Participating Provider.  Your condition must meet criteria for Medically Necessary hospitalization. EWCLGDED1983ACT0124 50 WAPEBB-CL-ACT