Temporomandibular Joint (TMJ) Medical and surgical services and related hospital charges for Hospital - Inpatient: After Deductible, Enrollee the treatment of temporomandibular joint (TMJ) disorders pays 50% Plan Coinsurance including: • Medically Necessary orthognathic procedures for the Hospital - Outpatient: After Deductible, Enrollee treatment of severe TMJ disorders which have failed pays 50% Plan Coinsurance non-surgical intervention. • Radiology services. Outpatient Services: After Deductible, Enrollee • TMJ specialist services. pays 50% Plan Coinsurance • Fitting/adjustment of splints. Non-Emergency inpatient hospital services require Preauthorization. TMJ appliances. See Devices, Equipment and Supplies for After Deductible, Enrollee pays 50% coinsurance additional information. Exclusions: Treatment for cosmetic purposes; bite blocks; dental services including orthodontic therapy and braces for any condition; any orthognathic (jaw) surgery in the absence of a diagnosis of TMJ or severe obstructive sleep apnea; hospitalizations related to these exclusions Tobacco Cessation Individual/group counseling and educational materials. No charge; Enrollee pays nothing Approved pharmacy products. See Drugs – Outpatient No charge; Enrollee pays nothing Prescription for additional pharmacy information. Transplants Transplant services, including heart, heart-lung, single lung, Hospital - Inpatient: After Deductible, Enrollee double lung, kidney, pancreas, cornea, intestinal/multi- pays 10% Plan Coinsurance visceral, liver transplants, and bone marrow and stem cell support (obtained from allogeneic or autologous peripheral Hospital - Outpatient: After Deductible, Enrollee blood or marrow) with associated high dose chemotherapy. pays 10% Plan Coinsurance Services are limited to the following: Outpatient Services: After Deductible, Enrollee • Inpatient and outpatient medical expenses for evaluation pays 10% Plan Coinsurance testing to determine recipient candidacy, donor matching tests, hospital charges, procurement center fees, professional fees, travel costs for a surgical team and excision fees. Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. • Follow-up services for specialty visits • Rehospitalization • Maintenance medications during an inpatient stay Organ Transplant Recipient: All services and supplies related to the organ transplant, including transportation to and PEBB HMOHSA 2024 44