2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 13 Medical Benefits Chart Services that are covered for you What you must pay when you get these services • Communication devices to allow you to contact Medically Home's command center 24 hours a day, 7 days a week. This includes needed communication technology to support reliable communication, and a PERS alert device to contact Medically Home's command center if you are unable to get to a phone. • Equipment necessary to ensure that you are monitored appropriately in your home: Blood pressure cuff/monitor, pulse oximeter, scale, and thermometer. • Laboratory tests, mobile imaging (X-rays, ultrasounds), and EKGs. • The following safety items: Shower stools, raised toilet seats, grabbers, long handle shoehorn, and sock aid. • Meals while you are receiving acute care in the home. In addition, for Medicare-covered services and items listed below, the cost-sharing indicated elsewhere in this Medical Benefits Chart does not apply when the services and items are prescribed as part of your Kaiser Permanente at Home treatment plan: • Durable medical equipment. • Medical supplies. • Ambulance transportation to and from network facilities when ambulance transport is medically necessary. • Physician assistant and nurse practitioner house calls. • The following services at a network facility if the services $0 are part of your home treatment plan: ♦ Network Emergency Department visits associated with this program. The cost-sharing indicated elsewhere in this Medical Benefits Chart will apply to all other services and items that aren't part of your Kaiser Permanente at Home treatment plan (for example, DME not specified in your Kaiser Permanente at Home treatment plan) or are part of your home treatment plan, but are not provided in your home except as listed above. † 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. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.