completed within the treatment plan time frames. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment 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 $250 Copayment per day up to $1,250 per transplants. Dental services (evaluation and treatment) in admission preparation for treatment require Preauthorization. Hospital - Outpatient: After Deductible, Enrollee Dental problems such as infections requiring emergency pays $200 Copayment treatment outside of standard business hours are covered as Emergency Services. Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment 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 $250 Copayment per day up to $1,250 per or are physically or developmentally disabled or have a admission Medical Condition where the Enrollee’s health would be put at risk if the dental procedure were performed in a dentist’s Hospital - Outpatient: After Deductible, Enrollee office. pays $200 Copayment 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 Enrollee pays 20% coinsurance repeated use, is primarily and customarily used to serve a medical purpose, is useful only in the presence of an illness or Covered wigs or hairpieces limited to $100 lifetime injury and is used in the Enrollee’s home. maximum • Examples of covered durable medical equipment Annual Deductible does not apply to strip-based includes hospital beds, wheelchairs, walkers, crutches, blood glucose monitors, test strips, lancets or control canes, blood glucose monitors, external insulin pumps solutions. (including related supplies such as tubing, syringe cartridges, cannulae and inserters), oxygen and the rental of equipment to administer oxygen (including tubing, connectors and masks), and therapeutic shoes, modifications and shoe inserts for severe diabetic foot disease. KFHPWA will determine if equipment is made available on a rental or purchase basis. • Orthopedic appliances: Items attached to an impaired body segment for the purpose of protecting the segment PEBB_VA_2024 17