covered when Medically Necessary due to a change in the Enrollee’s condition. • Prosthetic devices: Items which replace all or part of an external body part, or function thereof. • Sales tax for devices, equipment and supplies. • Wigs or hairpieces for hair loss due to radiation or chemotherapy. When provided in lieu of hospitalization, benefits will be the greater of benefits available for devices, equipment and supplies, home health or hospitalization. See Advanced Care at Home for durable medical equipment provided in an Advanced Care at Home setting. See Hospice for durable medical equipment provided in a hospice setting. Devices, equipment and supplies including repair, adjustment or replacement of appliances and equipment require Preauthorization. Exclusions: Arch supports, including custom shoe modifications or inserts and their fittings not related to the treatment of diabetes; orthopedic shoes that are not attached to an appliance; wigs/hair prosthesis (except as noted above); take-home dressings and supplies following hospitalization; supplies, dressings, appliances, devices or services not specifically listed as covered above; same as or similar equipment already in the Enrollee’s possession; replacement or repair due to loss, theft, breakage from willful damage, neglect or wrongful use, or due to personal preference; structural modifications to a Enrollee’s home or personal vehicle Diabetic Education, Equipment and Pharmacy Supplies Diabetic education and training. After Deductible, Enrollee pays 10% Plan Coinsurance Diabetic equipment: Blood glucose monitors and external After Deductible, Enrollee pays 10% Plan insulin pumps (including related supplies such as tubing, Coinsurance syringe cartridges, cannulae and inserters), and therapeutic shoes, modifications and shoe inserts for severe diabetic foot Annual Deductible does not apply to strip-based disease. See Devices, Equipment and Supplies for additional blood glucose monitors, test strips, lancets or control information. solutions Diabetic pharmacy supplies: Insulin, lancets, lancet devices, Certain Preventive medications as determined by needles, insulin syringes, disposable insulin pens, pen KFHPWA: No charge; Enrollee pays nothing needles, glucagon emergency kits, prescriptive oral agents and blood glucose test strips for a supply of 30 days or less Preferred generic drugs (Tier 1): After Deductible, per item. Certain brand name insulin drugs will be covered at Enrollee pays $20 Copayment per 30-days up to a the generic level. See Drugs – Outpatient Prescription for 90-day supply additional pharmacy information. Preferred brand name drugs (Tier 2): After Deductible, Enrollee pays $40 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Enrollee pays 50% PEBB HMOHSA 2024 18