Hospital - Outpatient: After Deductible, Enrollee Evaluation and a written treatment plan must be completed pays 15% Plan Coinsurance within 30 days from the date of injury. Treatment must be completed within the treatment plan time frames. 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 Other dental services: Not covered, Enrollee pays 100% of all charges Dental services in preparation for treatment including but not Hospital - Inpatient: After Deductible, Enrollee limited to: chemotherapy, radiation therapy, and organ pays $500 Copayment per admission transplants. Dental services (evaluation and treatment) in preparation for treatment require Preauthorization. Hospital - Outpatient: After Deductible, Enrollee pays 15% Plan Coinsurance Dental problems such as infections requiring emergency treatment outside of standard business hours are covered as Outpatient Services: Enrollee pays $20 Copayment Emergency Services. for primary care provider office visits After Deductible, Enrollee pays 15% Plan Coinsurance for specialty care provider office visits General anesthesia services and related facility charges for Hospital - Inpatient: After Deductible, Enrollee dental procedures for Enrollees who are under 7 years of age pays $500 Copayment per admission or are physically or developmentally disabled or have a Medical Condition where the Enrollee’s health would be put Hospital - Outpatient: After Deductible, Enrollee at risk if the dental procedure were performed in a dentist’s pays 15% Plan Coinsurance office. General anesthesia services for dental procedures require Preauthorization. Exclusions: Injuries caused by biting or chewing; malocclusion as a result from an accidental injury; reconstructive surgery to the jaw in preparation for dental implants, dental implants, orthodontia; treatment not completed within the written treatment plan time frame, unless treatment is delayed due to a medical condition and the treatment plan is modified; any other dental service not specifically listed as covered Devices, Equipment and Supplies (for home use) Durable medical equipment: Equipment which can withstand After Deductible, Enrollee pays 15% Plan repeated use, is primarily and customarily used to serve a Coinsurance medical purpose, is useful only in the presence of an illness or injury and is used in the Enrollee’s home. Covered wigs or hairpieces limited to $100 lifetime maximum • Examples of covered durable medical equipment includes hospital beds, wheelchairs, walkers, crutches, Annual Deductible does not apply to strip-based canes, blood glucose monitors, external insulin pumps blood glucose monitors, test strips, lancets or control (including related supplies such as tubing, syringe solutions. cartridges, cannulae and inserters), oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks), and therapeutic shoes, PEBB_SCA_2024 17