Other dental services: Not covered, Enrollee pays 100% of all charges Dental services in preparation for treatment including but not Hospital - Inpatient: After Deductible, Enrollee limited to: chemotherapy, radiation therapy, and organ pays 10% Plan Coinsurance transplants. Dental services (evaluation and treatment) in preparation for treatment require Preauthorization. Hospital - Outpatient: After Deductible, Enrollee pays 10% Plan Coinsurance Dental problems such as infections requiring emergency treatment outside of standard business hours are covered as Outpatient Services: After Deductible, Enrollee Emergency Services. pays 10% Plan Coinsurance General anesthesia services and related facility charges for Hospital - Inpatient: After Deductible, Enrollee dental procedures for Enrollees who are under 7 years of age pays 10% Plan Coinsurance or are physically or developmentally disabled or have a Medical Condition where the Enrollee’s health would be put Hospital - Outpatient: After Deductible, Enrollee at risk if the dental procedure were performed in a dentist’s pays 10% Plan Coinsurance office. General anesthesia services for dental procedures require Preauthorization. Exclusions: Injuries caused by biting or chewing; malocclusion as a result from an accidental injury reconstructive surgery to the jaw in preparation for dental implants, dental implants, orthodontia; treatment not completed within the written treatment plan time frame, unless treatment is delayed due to a medical condition and the treatment plan is modified; any other dental service not specifically listed as covered Devices, Equipment and Supplies (for home use) Durable medical equipment: Equipment which can withstand After Deductible, Enrollee pays 10% Plan repeated use, is primarily and customarily used to serve a Coinsurance medical purpose, is useful only in the presence of an illness or injury and is used in the Enrollee’s home. Covered wigs or hairpieces limited to $100 lifetime maximum • Examples of covered durable medical equipment includes hospital beds, wheelchairs, walkers, crutches, Annual Deductible does not apply to strip-based canes, blood glucose monitors, external insulin pumps blood glucose monitors, test strips, lancets or control (including related supplies such as tubing, syringe solutions cartridges, cannulae and inserters), oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks), and therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease. KFHPWA will determine if equipment is made available on a rental or purchase basis. • Orthopedic appliances: Items attached to an impaired body segment for the purpose of protecting the segment or assisting in restoration or improvement of its function. • Ostomy supplies: Supplies for the removal of bodily secretions or waste through an artificial opening. • Post-mastectomy bras/forms, limited to 2 every 6 months. Replacements within this 6-month period are PEBB HMOHSA 2024 17