2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 53 Chapter 4: Medical Benefits Chart (what is covered and what you pay) or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. • You receive your care from a network provider. In most cases, care you receive from an out- of-network provider will not be covered, unless it is emergent or urgent care or unless your plan or a network provider has given you a referral. This means that you will have to pay the provider in full for the services furnished. • You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP must give you approval in advance before you can see other providers in our plan's network. This is called giving you a referral. • Some of the services listed in the Medical Benefits Chart found at the front of this EOC are covered only if your doctor or other network provider gets approval in advance (sometimes called prior authorization) from us. Covered services that need approval in advance are marked in the Medical Benefits Chart with a footnote (†). In addition, see Chapter 3, Section 2.3, for more information about prior authorization, including other services that require prior authorization that are not listed in the Medical Benefits Chart. Other important things to know about our coverage • Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, you pay more in our plan than you would in Original Medicare. For others, you pay less. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2024 handbook. View it online at www.medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.) • For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, cost-sharing will apply for the care received for the existing medical condition. Apple symbol graphci ♦ You will see this apple next to the preventive services in the Medical Benefits Chart found at the front of this EOC. • If Medicare adds coverage for any new services during 2024, either Medicare or our plan will cover those services. Section 3 — What services are not covered by our plan? Section 3.1 – Services we do not cover (exclusions) This section tells you what services are excluded from Medicare coverage and, therefore, are not covered by this plan. The chart below lists services and items that either are not covered under any condition or are covered only under specific conditions. If you get services that are excluded (not covered), you must pay for them yourself except under the specific conditions listed below. Even if you receive the excluded services at an emergency facility, the excluded services are still not covered, and our plan will not pay for them. The only 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.