Table of Contents Table of Contents ......................................................................................................................................................... 3 I. Introduction ................................................................................................................................................... 6 II. How Covered Services Work ........................................................................................................................ 6 A. Accessing Care. ........................................................................................................................................ 6 B. Administration of the EOC. ..................................................................................................................... 9 C. Assignment. .............................................................................................................................................. 9 D. Confidentiality.......................................................................................................................................... 9 E. Modification of the EOC. ......................................................................................................................... 9 F. Nondiscrimination. ................................................................................................................................... 9 G. Preauthorization. .................................................................................................................................... 10 H. Recommended Treatment. ..................................................................................................................... 10 I. Second Opinions. ................................................................................................................................... 10 J. Unusual Circumstances. ......................................................................................................................... 10 K. Utilization Management. ........................................................................................................................ 11 III. Financial Responsibilities ........................................................................................................................... 11 A. Premium. ................................................................................................................................................ 11 B. Financial Responsibilities for Covered Services. ................................................................................... 11 C. Financial Responsibilities for Non-Covered Services. ........................................................................... 11 IV. Benefits Details ............................................................................................................................................ 12 Annual Deductible ......................................................................................................................................... 12 Prescription Drug Deductible ........................................................................................................................ 12 Coinsurance ................................................................................................................................................... 12 Lifetime Maximum ....................................................................................................................................... 12 Medical Out-of-pocket Limit ........................................................................................................................ 12 Prescription Drug Out-of-pocket Limit ......................................................................................................... 12 Pre-existing Condition Waiting Period ......................................................................................................... 12 Acupuncture .................................................................................................................................................. 13 Advanced Care at Home ................................................................................................................................ 13 Allergy Services ............................................................................................................................................ 15 Ambulance .................................................................................................................................................... 15 Cancer Screening and Diagnostic Services ................................................................................................... 15 Circumcision ................................................................................................................................................. 16 Clinical Trials ................................................................................................................................................ 16 Dental Services and Dental Anesthesia ......................................................................................................... 16 Devices, Equipment and Supplies (for home use) ......................................................................................... 17 Diabetic Education, Equipment and Pharmacy Supplies .............................................................................. 18 Dialysis (Home and Outpatient) .................................................................................................................... 19 Drugs – Outpatient Prescription .................................................................................................................... 20 Emergency Services ...................................................................................................................................... 23 Gender Health Services ................................................................................................................................. 24 Hearing Examinations and Hearing Aids ...................................................................................................... 24 Home Health Care ......................................................................................................................................... 25 Hospice .......................................................................................................................................................... 26 PEBB_CA_2024 3