Kaiser Permanente Sr Adv Basic Santa Clara (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Kaiser Permanente
- Rx
- Dental
- Vision
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $5 copay
Out-of-network: $20 copay
Out-of-network: $0 copay
Emergency Room
$130 copay
Ambulance Coverage
In-network: $300 copay
Out-of-network: $300 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0 copay
Out-of-network: $0 copay
Lab services:
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$275 copay
Out-of-network: $0-$275 copay
Outpatient x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$320 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $0-$300 copay
Out-of-network: $0-$300 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $7-$15 copay
Out-of-network: $7-$15 copay
Urgent Care Coverage
$130 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$150 per day for days 21-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $2 copay
Out-of-network: $2 copay
Outpatient individual therapy with a psychiatrist:
In-network: $5 copay
Out-of-network: $5 copay
Outpatient group therapy visits:
In-network: $2 copay
Out-of-network: $2 copay
Outpatient individual therapy visit:
In-network: $5 copay
Out-of-network: $5 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $5 copay
Out-of-network: $5 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$120.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$90.00 copay (30-day supply)
$270.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
33% coinsurance (90-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$80.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$90.00 copay (30-day supply)
$180.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
33% coinsurance (90-day supply)
Additional Added Benefits
Plan Links
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