2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 7 Medical Benefits Chart Services that are covered for you What you must pay when you get these services high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. Diabetes self-management training, diabetic services, and supplies For all people who have diabetes (insulin and noninsulin users), covered services include: $0 • †Supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors. • †For people with diabetes who have severe diabetic foot disease: One pair per calendar year of therapeutic custom- molded shoes (including inserts provided with such shoes) $0 and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the noncustomized removable inserts provided with such shoes). Coverage includes fitting. Diabetes self-management training is covered under $0 certain conditions. Durable medical equipment (DME) and related • $0 for ultraviolet light therapy supplies† equipment for psoriasis treatment, (For a definition of durable medical equipment, see CADD pumps, bone/spine Chapter 10 as well as Chapter 3, Section 7, of this document.) stimulators, and ventilators and Covered items include, but are not limited to: Wheelchairs, enteral pumps/supplies crutches, powered mattress systems, diabetic supplies, • $0 for all other DME hospital beds ordered by a provider for use in the home, IV Oxygen equipment infusion pumps, speech-generating devices, oxygen Your cost sharing for Medicare oxygen equipment, nebulizers, and walkers. equipment coverage is 20%, every time We cover all medically necessary DME covered by Original you receive equipment. Medicare. If our supplier in your area does not carry a Your cost sharing will not change after particular brand or manufacturer, you may ask them if they being enrolled for 36 months. † 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.