2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 41 Chapter 3: Using our plan for your medical services • Emergency services from network providers or from out-of-network providers. • Urgently needed services are covered services that are not emergency services, provided when the network providers are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For example, you need immediate care during the weekend. Services must be immediately needed and medically necessary. • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside our service area. If possible, please call Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away. • Second opinions from another network provider except for certain specialty care. • Medicare-covered preventive care as specified in the Medical Benefits Chart found at the front of this EOC. • Outpatient care for mental health at network Mental Health Departments. • Routine vision exams. • Routine hearing exams. • Cancer counseling. Section 2.3 – How to get care from specialists and other network providers A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples: • Oncologists care for patients with cancer. • Cardiologists care for patients with heart conditions. • Orthopedists care for patients with certain bone, joint, or muscle conditions. Referrals from your PCP You will usually see your PCP first for most of your routine health care needs. There are only a few types of covered services you may get on your own, without getting approval from your PCP first, which are described in Section 2.2 of this chapter. Referrals to network providers When your PCP prescribes care that isn't available from a PCP (for example, specialty care), they will give you a referral to see a network specialist or another network provider as needed. If your PCP refers you to a network specialist, the referral will be for a specific treatment plan. Your treatment plan may include a standing referral if ongoing care from the specialist is prescribed. We will send you a written referral to authorize an initial consultation or a specified number of visits with a network specialist. After your initial consultation with the network specialist, you must then return to your PCP unless we have authorized more visits as specified in the written referral that we gave you. Don't return to the network specialist after your initial consultation visit unless we have authorized additional visits in your referral. Otherwise, the services may not be covered. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.