Preauthorization. TMJ appliances. See Devices, Equipment and Supplies for Enrollee pays 50% coinsurance additional information. Exclusions: Treatment for cosmetic purposes; bite blocks; dental services including orthodontic therapy and braces for any condition; any orthognathic (jaw) surgery in the absence of a diagnosis of TMJ or severe obstructive sleep apnea; hospitalizations related to these exclusions Tobacco Cessation Individual/group counseling and educational materials. No charge; Enrollee pays nothing Approved pharmacy products. See Drugs – Outpatient No charge; Enrollee pays nothing Prescription for additional pharmacy information. Transplants Transplant services, including heart, heart-lung, single lung, Hospital - Inpatient: After Deductible, Enrollee double lung, kidney, pancreas, cornea, intestinal/multi- pays $150 Copayment per day up to $750 per visceral, liver transplants, and bone marrow and stem cell admission support (obtained from allogeneic or autologous peripheral blood or marrow) with associated high dose chemotherapy. Hospital - Outpatient: After Deductible, Enrollee pays $150 Copayment Services are limited to the following: • Inpatient and outpatient medical expenses for evaluation Outpatient Services: After Deductible, Enrollee testing to determine recipient candidacy, donor matching pays $15 primary care provider services Copayment tests, hospital charges, procurement center fees, or $30 specialty care provider services Copayment professional fees, travel costs for a surgical team and excision fees. Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. • Follow-up services for specialty visits • Rehospitalization • Maintenance medications during an inpatient stay Organ Transplant Recipient: All services and supplies related to the organ transplant, including transportation to and from KFHPWA Facilities (beyond the distance the Enrollee would normally be required to travel for most hospital services), are covered in accordance with the transplant benefit language, provided the Enrollee is accepted into the treating facility’s transplant program and continues to follow that program’s prescribed protocol. Organ Transplant Donor: The costs related to organ removal, as well as the cost of treating complications directly resulting from surgery, are covered, provided the organ recipient is an Enrollee under this Agreement, and provided the donor is not eligible for coverage under any other health care plan or government-funded program. PEBB_CA_2024 44