covered as Preventive Services. Circumcision Circumcision. (No charge if provided within 60 days of birth) Non-Emergency inpatient hospital services require Hospital - Inpatient: After Deductible, Enrollee Preauthorization. pays $500 Copayment per admission Hospital - Outpatient: After Deductible, Enrollee pays 15% Plan Coinsurance Outpatient Services: Enrollee pays $20 Copayment for primary care provider office visits After Deductible, Enrollee pays 15% Plan Coinsurance for specialty care provider office visits Clinical Trials Notwithstanding any other provision of this document, the Hospital - Inpatient: After Deductible, Enrollee Plan provides benefits for Routine Patient Costs of qualified pays $500 Copayment per admission individuals in approved clinical trials, to the extent benefits for these costs are required by federal and state law. Hospital - Outpatient: After Deductible, Enrollee pays 15% Plan Coinsurance Routine patient costs include all items and services consistent with the coverage provided in the plan (or coverage) that is Outpatient Services: Enrollee pays $20 Copayment typically covered for a qualified individual who is not for primary care provider office visits enrolled in a clinical trial. After Deductible, Enrollee pays 15% Plan Clinical trials are a phase I, phase II, phase III, or phase IV Coinsurance for specialty care provider office visits clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition. “Life threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Clinical trials require Preauthorization. Exclusions: Routine patient costs do not include: (i) the investigational item, device, or service, itself; (ii) items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; or (iii) a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis Dental Services and Dental Anesthesia Dental services including accidental injury to natural teeth. Accidental injury: Hospital - Inpatient: After Deductible, Enrollee Dental services (i.e., examination, evaluation and treatment) pays $500 Copayment per admission necessitated by accidental injury to sound natural teeth. PEBB_SCA_2024 16