28 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 • 50% of the total cost up to $400 maximum for a 31- to 90-day supply from our Mail-Order Pharmacy, per prescription Specialty drugs • 50% of the total cost up to $200 maximum for up to a 30-day supply, per prescription $0 contraceptives Note: Insulin is covered at the generic drug tier cost-sharing. (See the Outpatient Prescription Drug Rider in the EOC for additional information.) Prostate cancer screening exams There is no coinsurance, copayment, or For men aged 50 and older, covered services include the deductible for an annual digital rectal following—once every 12 months: exam or PSA test. • Digital rectal exam. • Prostate Specific Antigen (PSA) test. Prosthetic devices and related supplies† Devices (other than dental) that replace all or part of a body part or function. These include but are not limited to: $0 for external prosthetic or orthotic Colostomy bags and supplies directly related to colostomy devices and supplies (including wound care, pacemakers, braces, prosthetic shoes, artificial limbs, care supplies) and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic $0 for surgically implanted internal devices, and repair and/or replacement of prosthetic devices. devices and enteral and parenteral Also includes some coverage following cataract removal or nutrition therapy cataract surgery (see Vision Care later in this section for more detail). Includes wigs following chemotherapy or radiation therapy (up to $100 benefit maximum per lifetime). † 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