2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 19 Medical Benefits Chart Services that are covered for you What you must pay when you get these services • Other drugs you take using durable medical equipment (such as nebulizers) that were authorized by our plan. • Clotting factors you give yourself by injection if you have hemophilia. • Immunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplant. • Certain oral anti-cancer drugs and anti-nausea drugs. • Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases. • Drugs that usually aren't self-administered by the patient $0 and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services. • Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post- $0 menopausal osteoporosis, and cannot self-administer the drug. • Antigens. • Certain drugs for home dialysis, including heparin, the $0 antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen®, Epoetin Alfa, Aranesp®, or Darbepoetin Alfa). Note: • We also cover some vaccines under our Part B prescription drug benefit. Obesity screening and therapy to promote sustained weight loss If you have a body mass index of 30 or more, we cover There is no coinsurance, copayment, or intensive counseling to help you lose weight. This counseling deductible for preventive obesity is covered if you get it in a primary care setting, where it can screening and therapy. be coordinated with your comprehensive prevention plan. Talk to your primary care doctor or practitioner to find out more. Opioid treatment program services† $0 for clinically administered Medicare Members of our plan with opioid use disorder (OUD) can Part B drugs when provided by an receive coverage of services to treat OUD through an Opioid Opioid Treatment Program † 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.