2024 Kaiser Permanente Senior Advantage - Group #7145 (Northern CA) Group #230178 (Southern CA)
Basics
Lifetime maximum
No maximum
Plan Year
2024
Offered To
Medicare Retirees
Body/Description
This plan pays benefits when you get care from your Kaiser Permanente doctor and when your doctor refers you to a hospital or specialist in the network. Most covered expenses are paid at 100%.
You will pay a copay for certain services.
You do not get benefits from this plan or from Medicare if you receive non-emergency care outside the network. When you enroll in this plan, you assign your Medicare benefits to the plan.
This document is a summary. Please refer to the plan Evidence of Coverage (EOC) for more details.
Coinsurance
100% after applicable co-pays
Office co-pay
$25 copay
Deductible
No deductible
Benefit Type
Medical
Annual maximum
$1,000 per individual
$2,000 family
$2,000 family
X-rays
100%
Maternity Hospital Stay
100%
Baby's First Exam
100%
Birthing Centers
100%
Midwives
100% in hospital; if outpatient office visit: $25 copay
If midwife is available at Kaiser Permanente
If midwife is available at Kaiser Permanente
Prenatal Visits
100%
Doctor Delivery Charge
100%
Reproductive Health
$25 copay
Mental Health
Kaiser Permanente must approve mental health care.
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 copay per visit, individual
$12 copay per visit, group
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 copay per visit, individual
$12 copay per visit, group
Autism
NA
Substance Abuse
INPATIENT DETOXIFICATION
$100%
OUTPATIENT CARE
[no visit limit]
$25 copay per visit, individual
$5 copay per visit, group
$100%
OUTPATIENT CARE
[no visit limit]
$25 copay per visit, individual
$5 copay per visit, group
Acupuncture
$15 copay
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Acupuncturists
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Acupuncturists
Allergy Tests
$25 copay
Allergy Treatment
$3 copay for injections
Alternative Medicine
Not covered
Ambulance charges
$50 copay
CT Scans
100%
Chiropractors
$15 copay
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Chiropractors
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Chiropractors
Christian Science Practitioners
Not covered
Cosmetic Surgery
Not covered
Dental Treatment
Not covered
Emergency Room
$65 copay (waived if admitted)
Urgent Care
$25 copay
Hearing Care
100% for routine exam during annual physical. Audiologist hearing exam $25 copay, Specialist visit to diagnose and treat hearing problems $25 copay. $1000 ALLOW/DEVICE; 1 DEVICE/EAR; 2 DEVICE(S) PER 36 MONTHS
Home Health Care
100%
Hospice Care
100%
Hospital Stay
100%
Infertility Treatment
$25 copay
Fertility Drugs: Covered under drug benefits; In Vitro, GIFT, and ZIFT: Not covered.
Fertility Drugs: Covered under drug benefits; In Vitro, GIFT, and ZIFT: Not covered.
Laboratory Charges
100%
Magnetic resonance imaging - MRI
100%
Durable Medical Equipment
100%
Occupational Therapy
$25 copay
Organ Transplants
Contact Kaiser Permanente for information on transplant coverage benefits
Skilled Nursing
100%
Up to 100 days per benefit period. More than 100 days not covered.
Benefit period renews after patient is out of facility for 60 consecutive days.
Up to 100 days per benefit period. More than 100 days not covered.
Benefit period renews after patient is out of facility for 60 consecutive days.
Physical Therapy
$25 copay
Surgery : Physician Services
INPATIENT
100%
OUTPATIENT
100% after Facility Charge copay
100%
OUTPATIENT
100% after Facility Charge copay
Surgery : Facility Charges
INPATIENT
100%
OUTPATIENT
$25 copay per procedure
100%
OUTPATIENT
$25 copay per procedure
Speech Therapy
NA
Tubal Ligation
NA
Vasectomy
$25 copay per procedure
X-rays
100%
Pharmacy (Retail)
KAISER PERMANENTE PHARMACY
Generic: $10 for up to a 30-day supply, $20 for a 31- to 60-day supply, or $30 for a 61- to 100-day supply
Brand: $30 for up to a 30-day supply, $60 for a 31- to 60-day supply, or $90 for a 61- to 100-day supply
Generic: $10 for up to a 30-day supply, $20 for a 31- to 60-day supply, or $30 for a 61- to 100-day supply
Brand: $30 for up to a 30-day supply, $60 for a 31- to 60-day supply, or $90 for a 61- to 100-day supply
Mail order drug program
KAISER PERMANENTE MAIL ORDER PHARMACY Generic: $10 for up to a 30-day supply, $20 for a 31- to 100-day supply. Brand: $30 for up to a 30-day supply, $60 for a 31- to 100-day supply.
Retiree and dependent members can get over-the-counter health and wellness products delivered to their residence at no cost.
Retiree and dependent members can get over-the-counter health and wellness products delivered to their residence at no cost.
Birth Control Pills
Included in Prescription Drug benefit
Physical exams for adults
100%
Physical exams for children
100%
Pap smears
100%
Mammograms
100%
Immunizations
100%
When office visit not required
When office visit not required
Prostate Specific Antigen test - PSA
100%
Well-woman visits
100%
Vision care
100%
$150 eyewear allowance every 24 months
Contact Kaiser for other vision benefit information
$150 eyewear allowance every 24 months
Contact Kaiser for other vision benefit information
Meals
Over-the-counter health and wellness products and prescriptions as well as fresh, healthy meals following an inpatient stay at a hospital or skilled nursing facility can be delivered to your door, at no cost. You can also get a free ride to and from appointments. The plan covers up to 24 one-way trips (50 miles per trip) per calendar year. See Cardinal at Work for details.
Transportation
Retiree and dependent members can get a ride to and from medical appointments at no cost. The plan covers up to 24 one-way trips (50 miles per trip) per calendar year.
Transgender Services
Call Kaiser Nor CA 510-752-7149 or So CA 323-857-3818 for resources. Kaiser offers a broad range of covered gender-affirming care services:
• Mental health care
• Office visits
• Lab and imaging services
• Hormone therapy visits and administration
• Pharmacy services
• Preoperative and postoperative exams
• Facial hair removal
• Vocal therapy
• Tracheal shave
• Mastectomy with chest reconstruction and
gender-affirming chest surgery
• Gender-affirming facial surgery
• Gender-affirming genital surgeries
• Inpatient hospital care
• Outpatient care
• Treatment for medical complications
• Travel and lodging (when referred by Kaiser Permanente to a facility outside your region)
• Mental health care
• Office visits
• Lab and imaging services
• Hormone therapy visits and administration
• Pharmacy services
• Preoperative and postoperative exams
• Facial hair removal
• Vocal therapy
• Tracheal shave
• Mastectomy with chest reconstruction and
gender-affirming chest surgery
• Gender-affirming facial surgery
• Gender-affirming genital surgeries
• Inpatient hospital care
• Outpatient care
• Treatment for medical complications
• Travel and lodging (when referred by Kaiser Permanente to a facility outside your region)
Travel and Lodging
Contact the plan for details
Benefit Perks
See Kaiser Sr Advantage Silver & Fit exercise program flyer on Cardinal at Work or call 877-427-4788.
Over-the-counter health and wellness products and prescriptions as well as fresh, healthy meals following an inpatient stay at a hospital or skilled nursing facility can be delivered to your door, at no cost. You can also get a free ride to and from appointments. The plan covers up to 24 one-way trips (50 miles per trip) per calendar year.
Over-the-counter health and wellness products and prescriptions as well as fresh, healthy meals following an inpatient stay at a hospital or skilled nursing facility can be delivered to your door, at no cost. You can also get a free ride to and from appointments. The plan covers up to 24 one-way trips (50 miles per trip) per calendar year.