Circumcision Circumcision. (No charge if provided within 60 days of birth) Non-Emergency inpatient hospital services require Hospital - Inpatient: After Deductible, Enrollee Preauthorization. pays $150 Copayment per day up to $750 per admission Hospital - Outpatient: After Deductible, Enrollee pays $150 Copayment Outpatient Services: After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment 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 $150 Copayment per day up to $750 per individuals in approved clinical trials, to the extent benefits admission for these costs are required by federal and state law. Hospital - Outpatient: After Deductible, Enrollee Routine patient costs include all items and services consistent pays $150 Copayment with the coverage provided in the plan (or coverage) that is typically covered for a qualified individual who is not Outpatient Services: After Deductible, Enrollee enrolled in a clinical trial. pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment 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 $150 Copayment per day up to $750 per necessitated by accidental injury to sound natural teeth. admission Evaluation and a written treatment plan must be completed Hospital - Outpatient: After Deductible, Enrollee within 30 days from the date of injury. Treatment must be pays $150 Copayment PEBB_CA_2024 16