2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 29 Medical Benefits Chart Services that are covered for you What you must pay when you get these services Pulmonary rehabilitation services† Comprehensive programs of pulmonary rehabilitation are covered for members who have moderate to very severe $20 per visit chronic obstructive pulmonary disease (COPD) and an order for pulmonary rehabilitation from the doctor treating the chronic respiratory disease. Residential substance use disorder and mental health treatment† We cover the following services when the services are provided in a licensed residential treatment facility that provides 24-hour individualized substance use disorder or mental health treatment, the services are generally and customarily provided by a substance use disorder or mental health residential treatment program in a licensed residential treatment facility, and the services are above the level of custodial care: • Individual and group counseling. $250 per admission • Medical services. Cost-sharing is charged per admission • Medication monitoring. to a residential treatment program. • Room and board. • Drugs prescribed by a network provider as part of your plan of care in the residential treatment facility in accord with our drug formulary guidelines if they are administered to you in the facility by medical personnel. • Discharge planning. There is no limit to the number of medically necessary days in our residential treatment program to treat mental health conditions and substance abuse when prescribed by a network provider. † 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.