2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 25 Medical Benefits Chart Services that are covered for you What you must pay when you get these services • Basic hearing and balance exams performed by a network Specialist office visits provider, if your doctor orders it to see if you need medical • $35 per visit treatment. Outpatient hospital department or • †Second opinion by another network provider prior to surgical center surgery. You pay the following per visit when it • †Nonroutine dental care (covered services are limited to is provided in an outpatient or surgery of the jaw or related structures, setting fractures of ambulatory surgery center, or in a the jaw or facial bones, extraction of teeth to prepare the hospital operating room, or in any jaw for radiation treatments of neoplastic cancer disease, or setting and a licensed staff member services that would be covered when provided by a monitors your vital signs as you regain physician). sensation after receiving drugs to reduce sensation or minimize discomfort: • $50 • Chemotherapy visits. $0 • †Ultraviolet light treatments. $5 per visit • †Visits for injections administered in outpatient settings. $0 • Certain telehealth services, including: Primary and specialty care, which includes inpatient hospital acute, inpatient hospital psychiatric, cardiac rehabilitation services, emergency services, urgently needed services, home health services, occupational therapy, mental health, podiatry services, psychiatric services, physical therapy and speech-language pathology services, outpatient substance abuse, dialysis services, kidney disease education services, diabetes self-management training, $0 preparation for surgery or a hospital stay, and follow up visits after a hospital stay, surgery, or Emergency Department visit. Services will only be provided by telehealth when deemed clinically appropriate by the network provider rendering the service. ♦ You have the option of getting these services through an in-person visit or by telehealth. If you choose to get one of these services by telehealth, you must use a network provider who offers the service by telehealth. We offer the following means of telehealth: † 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.