Alternative care arrangements may be covered as a cost- effective alternative in lieu of otherwise covered Medically Necessary hospitalization or other Medically Necessary institutional care with the consent of the Enrollee and recommendation from the attending physician or licensed health care provider. Alternative care arrangements in lieu of covered hospital or other institutional care must be determined to be appropriate and Medically Necessary based upon the Enrollee’s Medical Condition. Such care is covered to the same extent the replaced Hospital Care is covered. Alternative care arrangements require Preauthorization. Enrollees receiving the following nonscheduled services are required to notify KFHPWA by way of the Hospital notification line within 24 hours following any admission, or as soon thereafter as medically possible: acute withdrawal management services, Emergency psychiatric services, Emergency services, labor and delivery and inpatient admissions needed for treatment of Urgent Conditions that cannot reasonably be delayed until Preauthorization can be obtained. Coverage for Emergency services in a non-Network Facility and subsequent transfer to a Network Facility is set forth in Emergency Services. Non-Emergency hospital services require Preauthorization. Exclusions: Take home drugs, dressings and supplies following hospitalization; internally implanted insulin pumps, artificial larynx and any other implantable device that have not been approved by KFHPWA’s medical director Infertility (including sterility) General counseling and one consultation visit to diagnose After Deductible, Enrollee pays $15 primary care infertility conditions. provider services Copayment or $30 specialty care provider services Copayment Specific diagnostic services, treatment and prescription drugs. Not covered; Enrollee pays 100% of all charges Exclusions: Diagnostic testing and medical treatment of sterility and infertility regardless of origin or cause; all charges and related services for donor materials; all forms of artificial intervention for any reason including artificial insemination and in-vitro fertilization; prognostic (predictive) genetic testing for the detection of congenital and heritable disorders; cryopreservation services; surrogacy; any services not specifically listed as covered Infusion Therapy Administration of Medically Necessary infusion therapy in an After Deductible, Enrollee pays $15 primary care outpatient setting. provider services Copayment or $30 specialty care provider services Copayment Preauthorization is required. Administration of Medically Necessary infusion therapy in No charge; Enrollee pays nothing PEBB_CA_2024 27