Table of Contents I. Introduction ................................................................................................................................................... 6 II. How Covered Services Work ........................................................................................................................ 6 A. Accessing Care. ........................................................................................................................................ 6 B. Administration of the Evidence of Coverage. .......................................................................................... 9 C. Assignment. .............................................................................................................................................. 9 D. Confidentiality.......................................................................................................................................... 9 E. Modification of the Evidence of Coverage. ............................................................................................. 9 F. Nondiscrimination. ................................................................................................................................... 9 G. Preauthorization. ...................................................................................................................................... 9 H. Recommended Treatment. ..................................................................................................................... 10 I. Second Opinions. ................................................................................................................................... 10 J. Unusual Circumstances. ......................................................................................................................... 10 K. Utilization Management. ........................................................................................................................ 10 III. Financial Responsibilities ........................................................................................................................... 11 A. Premium. ................................................................................................................................................ 11 B. Financial Responsibilities for Covered Services. ................................................................................... 11 C. Financial Responsibilities for Non-Covered Services. ........................................................................... 11 IV. Benefits Details ............................................................................................................................................ 12 Annual Deductible ......................................................................................................................................... 12 Coinsurance ................................................................................................................................................... 12 Lifetime Maximum ....................................................................................................................................... 12 Out-of-pocket Limit ...................................................................................................................................... 12 Pre-existing Condition Waiting Period ......................................................................................................... 12 Acupuncture .................................................................................................................................................. 13 Advanced Care at Home ................................................................................................................................ 13 Allergy Services ............................................................................................................................................ 15 Ambulance .................................................................................................................................................... 15 Cancer Screening and Diagnostic Services ................................................................................................... 15 Circumcision ................................................................................................................................................. 16 Clinical Trials ................................................................................................................................................ 16 Dental Services and Dental Anesthesia ......................................................................................................... 16 Devices, Equipment and Supplies (for home use) ......................................................................................... 17 Diabetic Education, Equipment and Pharmacy Supplies .............................................................................. 18 Dialysis (Home and Outpatient) .................................................................................................................... 19 Drugs - Outpatient Prescription ..................................................................................................................... 19 Emergency Services ...................................................................................................................................... 23 Gender Health Services ................................................................................................................................. 24 Hearing Examinations and Hearing Aids ...................................................................................................... 24 Home Health Care ......................................................................................................................................... 25 Hospice .......................................................................................................................................................... 26 Hospital - Inpatient and Outpatient ............................................................................................................... 26 Infertility (including sterility) ........................................................................................................................ 27 Infusion Therapy ........................................................................................................................................... 27 Laboratory and Radiology ............................................................................................................................. 28 PEBB HMOHSA 2024 3