40 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 3: Using our plan for your medical services Section 2 — Use providers in our network to get your medical care Section 2.1 – You may choose a Primary Care Provider (PCP) to provide and oversee your medical care What is a PCP and what does the PCP do for you? As a member, you may choose one of our available network providers to be your primary care provider. Your primary care provider is a physician who meets state requirements and is trained to give you primary medical care. Your PCP will usually practice general medicine (also called adult or internal medicine and family practice). At some network facilities, if you prefer, you may choose an available nurse practitioner or physician assistant to be your primary care provider. PCPs are identified in the Provider Directory. Your PCP provides, prescribes, or authorizes medically necessary covered services. Your PCP will provide most of your routine or basic care and provide a referral as needed to see other network providers for other care you need. For example, to see a specialist, you usually need to get your PCP's approval first (this is called getting a "referral" to a specialist). There are a few types of covered services you can get on your own without contacting your PCP first (see Section 2.2 in this chapter). Your PCP will also coordinate your care. "Coordinating" your care includes checking or consulting with other network providers about your care and how it is going. In some cases, your PCP will need to get prior authorization (prior approval) from us (see Section 2.3 in this chapter for more information). How do you choose or change your PCP? You may change your PCP for any reason and at any time from our available PCPs, including if you need to select a new PCP because your PCP isn't part of our network of providers any longer. Your PCP selections will be effective immediately. When you call, tell us if you are seeing specialists or getting other covered services that need your PCP's approval (such as home health services and durable medical equipment) so we can tell you if you need to get a referral from your new PCP to continue the services. Also, if there is a particular network specialist or hospital that you want to use, check with us to find out if your PCP makes referrals to that specialist or uses that hospital. Please see your Provider Directory or call Member Services for more information about selecting a PCP and which providers are accepting new patients. Section 2.2 – What kinds of medical care can you get without a referral from your PCP? You can get the services listed below without getting approval in advance from your PCP: • Routine women's health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams, as long as you get them from a network provider. • Flu shots, COVID-19 vaccinations, Hepatitis B vaccinations, and pneumonia vaccinations, as long as you get them from a network provider. kp.org