Kaiser Permanente Senior Advantage Value (HMO-POS)
Health Insurance Company: Kaiser Permanente
Medicare Advantage Plan Details
- Rx
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0-55 copay per visit
Out-of-network: $0-55 copay per visit
Out-of-network: $0-55 copay
Emergency Room
$110 copay per visit (always covered)
Ambulance Coverage
In-network: $250 copay
Out-of-network: No Data
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $10-45 copay
Out-of-network: $0-25 copay
Medicare-covered lab services: In-network: $0 copay
Out-of-network: $0-25 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $10-190 copay
Out-of-network: $0-25 copay
Medicare-covered x-ray services: In-network: $10 copay
Out-of-network: $0-25 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-210 copay per visit
Out-of-network: No Data
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $320 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 90 and beyond
Out-of-network: Not Applicable
Inpatient hospital psychiatric:
In-network: $245 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: Not Applicable
Rehabilitation Coverage
Occupational therapy services:
In-network: $40 copay
Out-of-network: $0-55 copay
Physical therapy and speech and language therapy services:
In-network: $40 copay
Out-of-network: $0-55 copay
Urgent Care Coverage
$40 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $0 per day for days 1 through 20
$196 per day for days 21 through 100
Out-of-network: Not Applicable
Mental Health Coverage
Medicare-covered individual sessions: In-network: $0 copay
Out-of-network: $0-55 copay
Medicare-covered group sessions: In-network: $0 copay
Out-of-network: $0-55 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: Not covered
Prophylaxis (cleaning): Not covered
Dental x-rays: Not covered
Vision Benefits
Eye exams:
Routine eye exams: In-network: $35 copay
Out-of-network: No Data
Eyewear:
Contact Lenses: Not covered
Eyeglasses: Not covered
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $35 copay
Out-of-network: $0-55 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
$10.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 3: Preferred Brand
$45.00 copay (30-day supply)
$135.00 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
$10.00 copay (30-day supply)
$20.00 copay (90-day supply)
Tier 3: Preferred Brand
$45.00 copay (30-day supply)
$90.00 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)
Plan Links
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