Urgent Care Inside the KFHPWA Service Area, urgent care is covered at a Network Emergency Department: After Kaiser Permanente medical center, Kaiser Permanente urgent Deductible, Enrollee pays $300 Copayment care center or Network Provider’s office. Network Urgent Care Center: After Deductible, Outside the KFHPWA Service Area, urgent care is covered at Enrollee pays $30 primary care provider services any medical facility. Copayment or $50 specialty care provider services Copayment See Section XII. for a definition of Urgent Condition. Network Provider’s Office: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Non-Network Provider: After Deductible, Enrollee pays $300 Copayment V. General Exclusions In addition to exclusions listed throughout the EOC, the following are not covered: 1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an illness, injury, or physical disability, that are not specifically listed as covered in the EOC, except as required by federal or state law. 2. Services Related to Non-Covered Services: When a service is not covered, all services related to the non- covered service (except for the specific exceptions described below) are also excluded from coverage. Enrollees who have received a non-covered service, such as bariatric surgery, and develop an acute medical complication (such as band slippage, leak or infection) as a result, shall have coverage for Medically Necessary intervention to stabilize the acute medical complication. Coverage does not include complications that occur during or immediately following a non-covered service. Additional surgeries or other medical services in addition to Medically Necessary intervention to resolve acute medical complications resulting from non-covered services shall not be covered. 3. Services or supplies for which no charge is made, or for which a charge would not have been made if the Enrollee had no health care coverage or for which the Enrollee is not liable; services provided by a family member, or self-care. 4. Convalescent Care. 5. Services to the extent benefits are “available” to the Enrollee as defined herein under the terms of any vehicle, homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the Enrollee if the Enrollee receives benefits under the policy either as a named insured or as an insured individual under the policy definition of insured. 6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. PEBB_VA_2024 46