Administration of Medically Necessary infusion therapy in After Deductible, Enrollee pays nothing the home setting. To receive benefits for the administration of select infusion medications in the home setting, the drugs must be obtained through KFHPWA’s preferred specialty pharmacy and administered by a provider we identify. For a list of these specialty drugs or for more information about KFHPWA’s specialty pharmacy network, please go to the KFHPWA website at www.kp.org/wa/formulary or contact Member Services. Associated infused medications includes, but is not limited to: After Deductible, Enrollee pays 10% Plan • Antibiotics. Coinsurance • Hydration. • Chemotherapy. • Pain management. Preauthorization is required. Laboratory and Radiology Nuclear medicine, radiology, ultrasound and laboratory After Deductible, Enrollee pays 10% Plan services, including high end radiology imaging services such Coinsurance as CAT scan, MRI and PET which are subject to Preauthorization except when associated with Emergency Urine Drug Screening: After Deductible, Enrollee services or inpatient services. Please contact Enrollee pays nothing. Limited to 2 tests per calendar year. Services for any questions regarding these services. Benefits are applied in the order claims are received and processed. After allowance: After Deductible, Services received as part of an emergency visit are covered as Enrollee pays 10% Plan Coinsurance Emergency Services. Breast Exams: After minimum Deductible, Enrollee Preventive laboratory and radiology services are covered in pays nothing accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act Note: Breast exam services are required to be subject of 2010. The well care schedule is available in Kaiser to the minimum Deductible amount in order to meet Permanente medical centers, at www.kp.org/wa, or upon state law requirements ($1,600 individual/$3,200 request from Member Services. family). All other services are subject to the entire Annual Deductible. The minimum Deductible amount may increase as determined by federal law. Members will receive notification of any changes to the minimum Deductible amount. Manipulative Therapy Manipulative therapy of the spine and extremities when in After Deductible, Enrollee pays 10% Plan accordance with KFHPWA clinical criteria, limited to a total Coinsurance of 24 visits per calendar year without Preauthorization. Additional visits are covered with Preauthorization. Rehabilitation services, such as massage or physical therapy, provided with manipulations is covered under the Massage PEBB HMOHSA 2024 28