For outpatient prescription drug coverage and Cost Share information, please refer to the “Prescription Drugs, Insulin, and Diabetic Supplies” section in the EOC and “Benefit Summary”. Kaiser Permanente at Home Exclusions  Housekeeping or meal services that are not part of your Kaiser Permanente at Home treatment plan.  Any care provided by or for a family member.  Any other Services rendered in the home which are not specified in your Kaiser Permanente at Home treatment plan. 19. Massage Therapy We cover outpatient visits for therapeutic massage Services without prior authorization, when the Services are received from a Participating Provider and provided as outpatient Services in the provider’s office, up to the visit limit shown on your “Benefit Summary.” Therapeutic massage involves the manipulation of soft tissue structures of the body to help alleviate pain, muscle discomfort, and stress by helping to promote health and wellness. To locate a Participating Provider, visit www.chpgroup.com. The CHP Group is a Participating Provider we contract with to provide therapeutic massage Services. If you need assistance searching for a provider, or to verify the current participation status of a provider, or if you do not have access to the online directory, please contact Member Services. Massage Therapy Exclusions  Dermal friction technique.  East Asian massage and tui na.  Qi gong.  Services designed to maintain optimal health in the absence of symptoms. 20. Medical Foods and Formula We cover the following Medically Necessary medical foods and formula subject to Utilization Review by Kaiser using criteria developed by Medical Group and approved by Kaiser:  Elemental formula for the treatment of eosinophilic gastrointestinal associated disorder.  Enteral formula for home treatment of severe intestinal malabsorption when the formula comprises the sole or essential source of nutrition.  Medical foods and formula necessary for the treatment of phenylketonuria (PKU), specified inborn errors of metabolism, or other metabolic disorders. 21. Mental Health Services We cover mental health Services as found in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, including Services for treatment of eating disorders when associated with a diagnosis of a DSM categorized mental health condition, when Services are necessary for:  Crisis intervention.  Evaluation.  Treatment of mental disorders or chronic conditions that a mental health Participating Provider determines to be Medically Necessary and expects to result in objective, measurable improvement. EWCLGDED1983ACT0124 52 WAPEBB-CL-ACT