2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 1 Medical Benefits Chart Medical Benefits Chart: Senior Advantage with Creditable Prescription Drug Coverage Washington PEBB Group ID Number 1983 For group benefits effective January 1, 2024 through December 31, 2024 You will see this apple next to the preventive services in this Medical Benefits Chart. Services that are covered for you What you must pay when you get these services Maximum out-of-pocket amount $1,500 per person per year Abdominal aortic aneurysm screening There is no coinsurance, copayment, or A one-time screening ultrasound for people at risk. Our plan deductible for members eligible for this only covers this screening if you have certain risk factors and preventive screening. if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist. Acupuncture for chronic low back pain (physician- referred)† Covered services include: • Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances: ♦ For the purpose of this benefit, chronic low back pain is defined as: o Lasting 12 weeks or longer. o Nonspecific, in that it has no identifiable systemic $20 per visit cause (i.e., not associated with metastatic, inflammatory, infectious disease, etc.). o Not associated with surgery. o Not associated with pregnancy. An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. † 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.