or assisting in restoration or improvement of its function. • Ostomy supplies: Supplies for the removal of bodily secretions or waste through an artificial opening. • Post-mastectomy bras/forms, limited to 2 every 6 months. Replacements within this 6-month period are 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 an Enrollee’s home or personal vehicle Diabetic Education, Equipment and Pharmacy Supplies Diabetic education and training. After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Diabetic equipment: Blood glucose monitors and external Enrollee pays 20% coinsurance insulin pumps (including related supplies such as tubing, syringe cartridges, cannulae and inserters), and therapeutic Annual Deductible does not apply to strip-based shoes, modifications and shoe inserts for severe diabetic foot blood glucose monitors, test strips, lancets or control disease. See Devices, Equipment and Supplies for additional solutions. information. Diabetic pharmacy supplies: Insulin, lancets, lancet devices, Value based medications which provide significant needles, insulin syringes, disposable insulin pens, pen value in treating chronic disease as determined by needles, glucagon emergency kits, prescriptive oral agents KFHPWA (Please contact Kaiser Permanente and blood glucose test strips for a supply of 30 days or less Member Services for a list of medications): Enrollee per item. Certain brand name insulin drugs will be covered at pays $5 Copayment the generic level. See Drugs – Outpatient Prescription for additional pharmacy information. Preferred generic drugs (Tier 1): Enrollee pays $20 Copayment per 30-days up to a 90-day supply PEBB_CA_2024 18