Allergy Services Allergy testing. After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Allergy serum and injections. After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Ambulance Emergency ambulance service is covered only when: Enrollee pays 20% coinsurance • Transport to the nearest facility that can treat your condition • Any other type of transport would put your health or safety at risk. • The service is from a licensed ambulance. • The ambulance transports you to a location where you receive covered services. Emergency air or sea medical transportation is covered only when: • The above requirements for ambulance service are met, and • Geographic restraints prevent ground Emergency transportation to the nearest facility that can treat your condition, or ground Emergency transportation would put your health or safety at risk. Non-Emergency ground or air interfacility transfer to or from Enrollee pays 20% coinsurance a Network Facility where you receive covered services when Preauthorized by KFHPWA. Contact Member Services for Hospital-to-hospital ground transfers: No charge; Preauthorization. Enrollee pays nothing Cancer Screening and Diagnostic Services Routine cancer screening covered as Preventive Services in No charge; Enrollee pays nothing accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. See Preventive Services for additional information. Diagnostic laboratory and diagnostic services for cancer. See After Deductible, Enrollee pays nothing Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. PEBB_CA_2024 15