Enrollee to a Network Facility upon consultation between a Network Provider and the attending physician. If the Enrollee refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission, all further costs incurred during the hospitalization are the responsibility of the Enrollee. Follow-up care which is a direct result of the Emergency must be received from a Network Provider, unless Preauthorization is obtained for such follow-up care from a non-Network Provider. Gender Health Services Medically Necessary medical and surgical services for gender Hospital - Inpatient: After Deductible, Enrollee affirmation. Consultation and treatment require pays $150 Copayment per day up to $750 per Preauthorization. Certain procedures are subject to age limits, admission please see our clinical criteria https://wa- provider.kaiserpermanente.org/static/pdf/hosting/clinical/crite Hospital - Outpatient: After Deductible, Enrollee ria/pdf/gender_reassignment_surgery.pdf for details. pays $150 Copayment Prescription drugs are covered the same as for any other Outpatient Services: After Deductible, Enrollee condition (see Drugs – Outpatient Prescription for coverage). pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Counseling services are covered the same as for any other condition (see Mental Health and Wellness for coverage). Non-Emergency inpatient hospital services require Preauthorization. Exclusions: Cosmetic services and surgery not related to gender affirming treatment (i.e., face lift or calf implants); complications of non-Covered Services Hearing Examinations and Hearing Aids Hearing exams for hearing loss and evaluation are covered Hospital - Inpatient: After Deductible, Enrollee only when provided at KFHPWA-approved facilities. pays $150 Copayment per day up to $750 per admission Cochlear implants and surgically implanted Bone Anchored Hearing System (BAHS) when in accordance with KFHPWA Hospital - Outpatient: After Deductible, Enrollee clinical criteria. pays $150 Copayment Covered services for initial cochlear implants and surgically Outpatient Services: After Deductible, Enrollee implanted BAHS include diagnostic testing, pre-implant pays $15 primary care provider services Copayment testing, implant surgery, post-implant follow-up, speech or $30 specialty care provider services Copayment therapy, programming and associated supplies (such as transmitter cable, and batteries). Replacement devices and associated supplies – see Devices, Equipment and Supplies Section. Hearing aids, externally worn bone conduction hearing Enrollee pays nothing, limited to an Allowance of PEBB_CA_2024 24