Infertility (including sterility) ........................................................................................................................ 28 Infusion Therapy ........................................................................................................................................... 28 Laboratory and Radiology ............................................................................................................................. 29 Manipulative Therapy ................................................................................................................................... 29 Massage Therapy ........................................................................................................................................... 29 Maternity and Pregnancy ............................................................................................................................... 30 Mental Health and Wellness .......................................................................................................................... 30 Naturopathy ................................................................................................................................................... 32 Newborn Services ......................................................................................................................................... 32 Nutritional Counseling .................................................................................................................................. 32 Nutritional Therapy ....................................................................................................................................... 32 Obesity Related Surgical Services................................................................................................................. 33 On the Job Injuries or Illnesses ..................................................................................................................... 33 Oncology ....................................................................................................................................................... 34 Optical (vision) .............................................................................................................................................. 34 Oral Surgery .................................................................................................................................................. 36 Outpatient Services ....................................................................................................................................... 36 Plastic and Reconstructive Surgery ............................................................................................................... 37 Podiatry ......................................................................................................................................................... 37 Preventive Services ....................................................................................................................................... 37 Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy .................................................................................. 38 Reproductive Health ...................................................................................................................................... 40 Sexual Dysfunction ....................................................................................................................................... 40 Skilled Nursing Facility................................................................................................................................. 41 Sterilization ................................................................................................................................................... 41 Substance Use Disorder................................................................................................................................. 42 Telehealth Services ....................................................................................................................................... 44 Temporomandibular Joint (TMJ) .................................................................................................................. 44 Tobacco Cessation ......................................................................................................................................... 45 Transplants .................................................................................................................................................... 45 Urgent Care ................................................................................................................................................. 46 V. General Exclusions ...................................................................................................................................... 46 VI. Eligibility, Enrollment and Termination ................................................................................................... 48 A. Eligibility. .............................................................................................................................................. 48 B. Enrollment for subscribers and dependents. ........................................................................................... 50 C. Medicare Eligibility and Enrollment. ..................................................................................................... 52 D. When Medical Coverage Begins. ........................................................................................................... 53 E. Making changes ..................................................................................................................................... 54 F. When medical coverage ends ................................................................................................................. 59 G. General provisions for eligibility and enrollment .................................................................................. 62 H. Appeal rights .......................................................................................................................................... 62 I. Relationship to law and regulations ....................................................................................................... 63 VII. Grievances .................................................................................................................................................... 63 VIII. Appeals ......................................................................................................................................................... 63 PEBB_SCA_2024 4