 Internally implanted devices, including cochlear implants, except for internally implanted insulin pumps.  Interrupted pregnancy surgery when performed in an inpatient setting.  Laboratory, X-rays and other imaging, and special diagnostic procedures.  Medical foods and formulas if Medically Necessary.  Medical social Services and discharge planning.  Operating and recovery rooms.  Orthognathic surgery and supplies for treatment of temporomandibular joint (TMJ) disorder or injury, sleep apnea or congenital anomaly.  Palliative care.  Participating Provider’s Services, including consultation and treatment by Specialists.  Prescription drugs, including injections.  Rehabilitative therapy Services such as massage (soft tissue mobilization), physical, occupational, and speech therapy Services.  Respiratory therapy.  Room and board, including a private room if Medically Necessary.  Specialized care and critical care units.  Temporomandibular joint (TMJ) surgery for the treatment of TMJ disorders subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser.  Vasectomy. Outpatient Hospital Services We cover outpatient Services for diagnosis, treatment, and preventive medicine upon payment of any applicable Cost Share shown in the “Benefit Summary” in the “Outpatient Services” section. Additional types of outpatient Services are covered as described under other headings in this “Benefits” section. Some outpatient Services may be subject to prior authorization from Company in accordance with Utilization Review criteria developed by Medical Group and approved by Company. For more information about Services that require Utilization Review, or to request a copy of the criteria for a specific condition or Service, please contact Member Services. Covered outpatient Services include but are not limited to:  Allergy testing and treatment materials.  Cardiac rehabilitative therapy visits.  Chemotherapy and radiation therapy Services.  Diagnostic Services and scope insertion procedures, such as colonoscopy, endoscopy, and laparoscopy.  Drugs, injectables, and radioactive materials used for therapeutic or diagnostic purposes, if they are administered to you in a Participating Medical Office or during home visits, subject to the drug formulary and exclusions described under the “Limited Outpatient Prescription Drugs and Supplies” section.  Emergency department visits.  Gender Affirming Treatment.  Internally implanted devices, including cochlear implants, except for internally implanted insulin pumps. EWCLGDED1983ACT0124 49 WAPEBB-CL-ACT