Primary Care Participating Providers ..................................................................................................................... 30 Women’s health Care Services ................................................................................................................................ 30 Referrals ...................................................................................................................................................................... 31 Referrals to Participating Providers and Participating Facilities .................................................................. 31 Referrals to Non-Participating Providers and Non-Participating Facilities ............................................... 32 Prior and Concurrent Authorization and Utilization Review ............................................................................. 32 Individual Case Management ............................................................................................................................ 33 Home Health Care Alternative to Hospitalization ........................................................................................ 33 Participating Providers and Participating Facilities Contracts ............................................................................ 34 Provider Whose Contract Terminates.................................................................................................................... 34 Receiving Care in Another Kaiser Foundation Health Plan Service Area ........................................................ 34 Post Service Claims – Services Already Received .................................................... 35 Emergency, Post-Stabilization, and Urgent Care ....................................................... 35 Emergency Services .................................................................................................................................................. 35 Post-Stabilization Care ............................................................................................................................................. 36 Urgent Care ................................................................................................................................................................ 37 Inside our Service Area ...................................................................................................................................... 37 Outside our Service Area .................................................................................................................................. 37 What You Pay ................................................................................................................ 37 Deductible .................................................................................................................................................................. 37 Copayments and Coinsurance ................................................................................................................................. 38 Out-of-Pocket Maximum ......................................................................................................................................... 38 Benefit Details ............................................................................................................... 38 1. Accidental Injury to Teeth ................................................................................................................................... 39 2. Administered Medications ................................................................................................................................... 39 3. Acupuncture Services ........................................................................................................................................... 39 4. Ambulance Services .............................................................................................................................................. 40 5. Bariatric Surgery and Weight Control and Obesity Treatment ...................................................................... 41 6. Services Provided in Connection with Clinical Trials ...................................................................................... 41 7. Diabetic Education ............................................................................................................................................... 42 8. Diagnostic Testing, Laboratory, Mammograms and X-ray ............................................................................ 42 9. Dialysis—Outpatient ............................................................................................................................................ 42 10. Durable Medical Equipment (DME) and External Prosthetic Devices and Orthotic Devices .............. 42 11. Emergency Services ............................................................................................................................................ 45 12. Habilitative Services ............................................................................................................................................ 45 13. Hearing Instruments ........................................................................................................................................... 46 14. Home Health Services ........................................................................................................................................ 47 15. Hospice Services ................................................................................................................................................. 47 16. Hospital Services ................................................................................................................................................. 48 EWCLGDED1983ACT0124 WAPEBB-CL-ACT