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 $50 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 $30 primary care accordance with KFHPWA clinical criteria, limited to a total provider services Copayment or $50 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. Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved; care rendered primarily for the convenience of the Enrollee; care rendered on a non-acute, asymptomatic basis; charges for any other services that do not meet KFHPWA clinical criteria as Medically Necessary Massage Therapy Visits with licensed massage therapists to restore function After Deductible, Enrollee pays $50 specialty care immediately following illness, injury or surgery, limited to a provider services Copayment combined total of 24 visits per calendar year without Preauthorization. Outpatient services require a prescription or order from a physician that reflects a written plan of care to restore function. Exclusions: Recreational; life-enhancing, relaxation or services designed to relieve or soothe symptoms of a disease or disorder without effecting a cure (palliative therapy); massage therapists preventive services; any services not within the scope of the practitioner’s licensure PEBB_VA_2024 29