2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 15 Medical Benefits Chart Services that are covered for you What you must pay when you get these services and follow plan rules (such as if there is a requirement to obtain prior authorization): • If you obtain the covered services from a network provider and follow plan rules for obtaining service, you only pay the plan cost-sharing amount for in-network services. • *If you obtain the covered services from an out-of-network provider, you pay the cost-sharing under Fee-for-Service Medicare (Original Medicare). For services that are covered by our plan but are not covered by Medicare Part A or B: We will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost-sharing amount for these services. Note: If you need nonhospice care (care that is not related to your terminal prognosis), you should contact us to arrange the services. We cover hospice consultation services for a terminally ill $0 person who hasn't elected the hospice benefit. Immunizations Covered Medicare Part B services include: • Pneumonia vaccine. • Flu shots, once each flu season in the fall and winter, with There is no coinsurance, copayment, or additional flu shots if medically necessary. deductible for the pneumonia, influenza, • Hepatitis B vaccine if you are at high or intermediate risk Hepatitis B, and COVID-19 vaccines. of getting Hepatitis B. • COVID-19 vaccine. • Other vaccines if you are at risk and they meet Medicare Part B coverage rules. Inpatient hospital care† $500 per admission Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day. † 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.