2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 3 Medical Benefits Chart Services that are covered for you What you must pay when you get these services (See the Naturopathic Medicine Rider in the EOC for additional information.) Ambulance services Covered ambulance services, whether for an emergency or †non-emergency situation, include fixed wing, rotary wing, and ground ambulance services to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person's health or if authorized by our plan. If the covered ambulance services are not for an emergency situation, it should be documented that the member's condition is such that other means of $50 per one-way trip transportation could endanger the person's health and that transportation by ambulance is medically required. We also cover the services of a licensed ambulance anywhere in the world without prior authorization (including transportation through the 911 emergency response system where available) if you reasonably believe that you have an emergency medical condition and you reasonably believe that your condition requires the clinical support of ambulance transport services. Annual routine physical exams There is no coinsurance, copayment, or Routine physical exams are covered if the exam is medically deductible for this preventive care. appropriate preventive care in accord with generally accepted professional standards of practice. Annual wellness visit If you've had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. There is no coinsurance, copayment, or This is covered once every 12 months. deductible for the annual wellness visit. Note: Your first annual wellness visit can't take place within 12 months of your Welcome to Medicare preventive visit. However, you don't need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you've had Part B for 12 months. † 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.