Circumcision Circumcision. (After Deductible, Enrollee pays nothing if provided within 60 days of birth) Non-Emergency inpatient hospital services require Preauthorization. Hospital - Inpatient: After Deductible, Enrollee pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Enrollee pays 10% Plan Coinsurance Outpatient Services: After Deductible, Enrollee pays 10% Plan Coinsurance Clinical Trials Notwithstanding any other provision of this document, the Hospital - Inpatient: After Deductible, Enrollee Plan provides benefits for Routine Patient Costs of qualified pays 10% Plan Coinsurance individuals in approved clinical trials, to the extent benefits for these costs are required by federal and state law. Hospital - Outpatient: After Deductible, Enrollee pays 10% Plan Coinsurance Routine patient costs include all items and services consistent with the coverage provided in the plan (or coverage) that is Outpatient Services: After Deductible, Enrollee typically covered for a qualified individual who is not pays 10% Plan Coinsurance enrolled in a clinical trial. Clinical Trials are a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition. “Life threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Clinical trials require Preauthorization. Exclusions: Routine patient costs do not include: (i) the investigational item, device, or service, itself; (ii) items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; or (iii) a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis Dental Services and Dental Anesthesia Dental services including accidental injury to natural teeth. Accidental Injury: Hospital - Inpatient: After Deductible, Enrollee Dental Services (i.e., examination, evaluation and treatment) pays 10% Plan Coinsurance necessitated by accidental injury to sound natural teeth. Hospital - Outpatient: After Deductible, Enrollee Evaluation and a written treatment plan must be completed pays 10% Plan Coinsurance within 30 days from the date of injury. Treatment must be completed within the treatment plan time frames. Outpatient Services: After Deductible, Enrollee pays 10% Plan Coinsurance PEBB HMOHSA 2024 16