Coverage for Emergency services in a non-Network Facility and subsequent transfer to a Network Facility is set forth in Emergency Services. Non-Emergency hospital services require Preauthorization. Exclusions: Take home drugs, dressings and supplies following hospitalization; internally implanted insulin pumps, artificial larynx and any other implantable device that have not been approved by KFHPWA’s medical director Infertility (including sterility) General counseling and one consultation visit to diagnose After Deductible, Enrollee pays $30 primary care infertility conditions. provider services Copayment or $50 specialty care provider services Copayment Specific diagnostic services, treatment and prescription drugs. Not covered; Enrollee pays 100% of all charges Exclusions: Diagnostic testing and medical treatment of sterility and infertility regardless of origin or cause; all charges and related services for donor materials; all forms of artificial intervention for any reason including artificial insemination and in-vitro fertilization; prognostic (predictive) genetic testing for the detection of congenital and heritable disorders; cryopreservation services; surrogacy; any services not specifically listed as covered Infusion Therapy Administration of Medically Necessary infusion therapy in an After Deductible, Enrollee pays $30 primary care outpatient setting. provider services Copayment or $50 specialty care provider services Copayment Preauthorization is required. Administration of Medically Necessary infusion therapy in No charge; Enrollee pays nothing the home setting. To receive benefits for the administration of select infusion medications in the home setting, the drugs must be obtained through KFHPWA’s preferred specialty pharmacy and administered by a provider we identify. For a list of these specialty drugs or for more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at www.kp.org/wa/formulary or contact Member Services. Associated infused medications includes, but is not limited to: After Deductible, Enrollee pays nothing • Antibiotics. • Hydration. • Chemotherapy. • Pain management. Preauthorization is required. PEBB_VA_2024 28