12 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 • Remote monitoring. • Monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier. We cover home infusion supplies and drugs if all of the $0 following are true: Note: If a covered home infusion supply • Your prescription drug is on our standard formulary (or or drug is not filled by a network home- you have a formulary exception). infusion pharmacy, the supply or drug • We approved your prescription drug for home infusion may be subject to the applicable cost- therapy. sharing listed elsewhere in this • Your prescription is written by a network provider and document depending on the service. filled at a network home-infusion pharmacy. Home medical care not covered by Medicare (Kaiser Permanente at Home)† This benefit is unavailable to members in Lane County. We cover medical care in your home that is not otherwise covered by Medicare in certain situations to provide you with an alternative to receiving acute care in a hospital. Services in the home must be: • Prescribed by a network hospitalist who has determined that based on your health status, treatment plan, and home setting that you can be treated safely and effectively in the home. $0 • Elected by you because you prefer to receive the care described in your treatment plan in your home. Services are provided or arranged by our plan and Medically Home. Medically Home is our network provider and will provide the following services and items in your home in accord with your treatment plan for as long as they are prescribed by a network hospitalist: • Home visits by RNs, physical therapists, occupational therapists, speech therapists, respiratory therapists, nutritionist, home health aides, and other healthcare professionals in accord with the home care treatment plan and the provider's scope of practice and license. † 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