provider services Copayment Limited to 3 visits per medical diagnosis per calendar year without Preauthorization. Additional visits are covered with Preauthorization. Laboratory and radiology services are covered only when obtained through a Network Facility. Exclusions: Herbal supplements; nutritional supplements; any services not within the scope of the practitioner’s licensure Newborn Services Newborn services are covered the same as for any other Hospital - Inpatient: After Deductible, Enrollee condition. Any Cost Share for newborn services is separate pays $250 Copayment per day up to $1,250 per from that of the mother. admission Preventive services for newborns are covered under During the baby’s initial hospital stay while the birth Preventive Services. mother and baby are both confined, any applicable Deductible and Copayment for the newborn are When an Enrollee gives birth, the newborn is entitled to the waived benefits set forth in the EOC from birth through 3 weeks of age. After 3 weeks of age, no benefits are available unless the Hospital - Outpatient: After Deductible, Enrollee newborn child qualifies as a Dependent and is enrolled. See pays $200 Copayment Section VI. for enrollment information. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Nutritional Counseling Nutritional counseling. After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care Services related to a healthy diet to prevent obesity are provider services Copayment covered as Preventive Services. See Preventive Services for additional information. Exclusions: Nutritional supplements; weight control self-help programs or memberships, such as Weight Watchers, Jenny Craig, or other such programs Nutritional Therapy Medical formula necessary for the treatment of After Deductible, Enrollee pays nothing phenylketonuria (PKU), specified inborn errors of metabolism, or other metabolic disorders. Enteral therapy is covered when Medical Necessity criteria After Deductible, Enrollee pays 20% coinsurance are met and when given through a PEG, J tube, or orally or for an eosinophilic gastrointestinal disorder. Necessary equipment and supplies for the administration of PEBB_VA_2024 32