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 $500 Copayment per admission visceral, liver transplants, and bone marrow and stem cell support (obtained from allogeneic or autologous peripheral Hospital - Outpatient: After Deductible, Enrollee blood or marrow) with associated high dose chemotherapy. pays 15% Plan Coinsurance Services are limited to the following: Outpatient Services: Enrollee pays $20 Copayment • Inpatient and outpatient medical expenses for evaluation for primary care provider office visits testing to determine recipient candidacy, donor matching tests, hospital charges, procurement center fees, After Deductible, Enrollee pays 15% Plan professional fees, travel costs for a surgical team and Coinsurance for specialty care provider office visits 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_SCA_2024 45