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 nothing • Antibiotics. • Hydration. • Chemotherapy. • Pain management. Preauthorization is required. Laboratory and Radiology Nuclear medicine, radiology, ultrasound and laboratory After Deductible, Enrollee pays nothing services. Urine Drug Screening: Enrollee pays nothing. Services received as part of an emergency visit are covered as Limited to 2 tests per calendar year. Benefits are Emergency Services. applied in the order claims are received and processed. After allowance: After Deductible, Preventive laboratory and radiology services are covered in Enrollee pays nothing accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act Breast Exams: Enrollee pays nothing of 2010. The well care schedule is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. CAT scan, MRI and PET which are subject to After Deductible, Enrollee pays $30 Copayment Preauthorization except when associated with Emergency services or inpatient services. Please contact Member Services for any questions regarding these services. Manipulative Therapy Manipulative therapy of the spine and extremities when in After Deductible, Enrollee pays $15 primary care accordance with KFHPWA clinical criteria, limited to a total provider services Copayment or $30 specialty care of 24 visits per calendar year. Preauthorization is not provider services Copayment required. Rehabilitation services, such as massage or physical therapy, provided with manipulations is covered under the Massage Therapy or Rehabilitation and Habilitative Care (occupational, physical and speech therapy, pulmonary and cardiac rehabilitation) and Neurodevelopmental Therapy section. PEBB_CA_2024 28