20 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Medical Benefits Chart Services that are covered for you What you must pay when you get these services Treatment Program (OTP), which includes the following services: • U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications. • Dispensing and administration of MAT medications (if applicable). • Substance use counseling. • Individual and group therapy. $35 per visit • Toxicology testing. • Intake activities. • Periodic assessments. Outpatient diagnostic tests and therapeutic services and supplies† Covered services include, but are not limited to: • Laboratory tests. $0 ♦ INR lab tests for persons with liver disease or certain bleeding disorders $0 ♦ A1c lab tests for persons with diabetes ♦ LDL lab tests for person with heart disease • Blood—including storage and administration. $0 • X-rays. • Electrocardiograms (EKGs), holter monitoring, and $0 electroencephalograms (EEGs). • Ultrasounds. • Sleep studies. • Radiation (radium and isotope) therapy, including $0 technician materials and supplies. • Surgical supplies, such as dressings. $0 for surgical supplies or casts • Splints, casts, and other devices used to reduce fractures $0 for take-home dressings and and dislocations. supplies, splints, and other devices to reduce fractures and dislocations † Your provider must obtain prior authorization from our plan. * Your cost-sharing for these services or items doesn't apply toward the maximum out-of-pocket amount. kp.org