Hospital - Inpatient and Outpatient ............................................................................................................... 26 Infertility (including sterility) ........................................................................................................................ 27 Infusion Therapy ........................................................................................................................................... 27 Laboratory and Radiology ............................................................................................................................. 28 Manipulative Therapy ................................................................................................................................... 28 Massage Therapy ........................................................................................................................................... 29 Maternity and Pregnancy ............................................................................................................................... 29 Mental Health and Wellness .......................................................................................................................... 30 Naturopathy ................................................................................................................................................... 31 Newborn Services ......................................................................................................................................... 31 Nutritional Counseling .................................................................................................................................. 31 Nutritional Therapy ....................................................................................................................................... 32 Obesity Related Surgical Services................................................................................................................. 32 On the Job Injuries or Illnesses ..................................................................................................................... 33 Oncology ....................................................................................................................................................... 33 Optical (vision) .............................................................................................................................................. 34 Oral Surgery .................................................................................................................................................. 35 Outpatient Services ....................................................................................................................................... 35 Plastic and Reconstructive Surgery ............................................................................................................... 36 Podiatry ......................................................................................................................................................... 36 Preventive Services ....................................................................................................................................... 36 Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy .................................................................................. 38 Reproductive Health ...................................................................................................................................... 39 Sexual Dysfunction ....................................................................................................................................... 40 Skilled Nursing Facility................................................................................................................................. 40 Sterilization ................................................................................................................................................... 40 Substance Use Disorder................................................................................................................................. 41 Telehealth Services ....................................................................................................................................... 43 Temporomandibular Joint (TMJ) .................................................................................................................. 43 Tobacco Cessation ......................................................................................................................................... 44 Transplants .................................................................................................................................................... 44 Urgent Care ................................................................................................................................................... 45 V. General Exclusions ...................................................................................................................................... 45 VI. Eligibility, Enrollment and Termination ................................................................................................... 47 A. Eligibility. .............................................................................................................................................. 47 B. Enrollment for subscribers and dependents. ........................................................................................... 49 C. Medicare Eligibility and Enrollment. ..................................................................................................... 51 D. When Medical Coverage Begins. ........................................................................................................... 52 E. Making changes ..................................................................................................................................... 53 F. When medical coverage ends ................................................................................................................. 58 G. General provisions for eligibility and enrollment .................................................................................. 61 H. Appeal rights .......................................................................................................................................... 61 I. Relationship to law and regulations ....................................................................................................... 62 VII. Grievances .................................................................................................................................................... 62 PEBB_CA_2024 4