Acupuncture Acupuncture needle treatment, limited to 24 visits per Enrollee pays $20 Copayment for primary care calendar year without Preauthorization. Additional visits are provider office visits covered with Preauthorization. After Deductible, Enrollee pays 15% Plan No visit limit for treatment for Substance Use Disorder. Coinsurance for specialty care provider office visits Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure Advanced Care at Home Advanced Care at Home is a personalized, patient-centered No charge, Enrollee pays nothing program that provides care for patients with certain clinical conditions in their homes, or at another appropriate care location such as a family member’s home or temporary residence. Advanced Care at Home services must be associated with an acute episode in which the member is treated for a brief but severe episode of illness, for conditions that are the result of disease such as, but not exclusive to, congestive heart failure, pneumonia, upper urinary tract infection or cellulitis. The treatment plan may include restorative care associated with the acute episode. The duration of an episode of care (which includes acute and restorative phases) is limited to a total of 30 days. To receive advanced care in the home: • The Enrollee must be referred into the advanced care program by the managing provider at an emergency room, urgent care or inpatient setting, • Advanced Care at Home requires Preauthorization based on the Enrollee’s health status, treatment plan, and home setting or another appropriate care location within the Service Area, • The clinical condition must meet inpatient Medical Necessity criteria, • The Enrollee must consent to receiving advanced care described in the treatment plan, • The care location, such as the Enrollee’s residence, must be within 30 minutes ground travel time of an emergency department, and • The care location, such as the Enrollee’s residence, must, have cell service. Advanced Care at Home is provided through Medically Home, our Network provider, and they will provide the following services in the Enrollee’s home or appropriate care location: • Home visits by RNs, physical therapists, occupational therapists, speech therapists, respiratory PEBB_SCA_2024 13