2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 27 Medical Benefits Chart Services that are covered for you What you must pay when you get these services ♦ The evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment. • Consultation your doctor has with other doctors by phone, internet, or electronic health record. Podiatry services† Specialist office visits Covered services include: • $35 per visit • Diagnosis and the medical or surgical treatment of injuries Outpatient hospital department or and diseases of the feet (such as hammer toe or heel spurs). surgical center • Routine foot care for members with certain medical You pay the following per visit when it conditions affecting the lower limbs. is provided in an outpatient or ambulatory surgery center, or in a hospital operating room, or in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort: • $50 *Prescription drugs† Generic drugs (Not covered by Medicare, but covered by your group plan.) • $20 for up to a 30-day supply, per prescription • $40 for a 31- to 90-day supply from our Mail-Order Pharmacy, per prescription Preferred brand drugs • $40 for up to a 30-day supply, per prescription • $80 for a 31- to 90-day supply from our Mail-Order Pharmacy, per prescription Non-preferred brand drugs • 50% of the total cost up to $200 maximum for up to a 30-day supply, per prescription † 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.