o A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants. o The Department of Veterans Affairs or the Department of Defense or the Department of Energy, but only if the study or investigation has been reviewed and approved through a system of peer review that the U.S. Secretary of Health and Human Services determines meets all of the following requirements:  It is comparable to the National Institutes of Health system of peer review of studies and investigations.  It assures unbiased review of the highest scientific standards by qualified people who have no interest in the outcome of the review. For covered Services related to a clinical trial, you will pay the Cost Share you would pay if the Services were not related to a clinical trial. For example, see “Hospital Services” in the “Benefit Summary” for the Cost Share that applies to hospital inpatient care. 7. Diabetic Education Medically Necessary diabetic education, including diabetic counseling and diabetic self-management training is covered. The Member’s PCP or Participating Provider must prescribe the Services. 8. Diagnostic Testing, Laboratory, Mammograms and X-ray Laboratory or special diagnostic procedures such as CT scans, MRI, mammograms, including tomosynthesis (3-D mammography), imaging, including X-ray, ultrasound imaging, cardiovascular testing, nuclear medicine, and allergy testing, prescribed by the Member’s PCP or Participating Provider, and provided at a Participating Facility are covered. Screening and special diagnostic procedures during pregnancy and related genetic counseling when Medically Necessary for prenatal diagnosis of congenital disorders are included. You must receive prior authorization by Kaiser for MRI, CT scans, PET scans, and bone density/DXA scans. (See “Prior and Concurrent Authorization and Utilization Review” in the “How to Obtain Services” section.) Some Services, such as preventive screenings and routine mammograms, are not covered under this “Diagnostic Testing, Laboratory, Mammograms and X-ray” benefit but may be covered under the “Preventive Care Services” section. We cover preventive care Services without charge. Diagnostic Testing, Laboratory, Mammograms and X-ray Limitations Covered genetic testing Services are limited to preconception and prenatal testing for detection of congenital and heritable disorders, and testing for the prediction of high-risk occurrence or reoccurrence of disease when Medically Necessary. These Services are subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser. 9. Dialysis—Outpatient Outpatient professional and facility Services necessary for dialysis when referred by the Member’s PCP or Participating Provider are covered. Dialysis is covered while you are temporarily absent from our Service Area. A temporary absence is an absence lasting less than twenty-one (21) days. Services must be preauthorized prior to departure from our Service Area. 10. Durable Medical Equipment (DME) and External Prosthetic Devices and Orthotic Devices This Plan covers the rental or purchase of Durable Medical Equipment (DME) and related medical supplies, External Prosthetic Devices, and Orthotic Devices. EWCLGDED1983ACT0124 42 WAPEBB-CL-ACT