Kaiser Permanente
Medicare Advantage HMO including Rx Coverage
Kaiser is committed to providing excellent care today, which leads to healthier tomorrows. Kaiser’s under one roof approach puts your doctor, specialist, lab, and pharmacy often in one location.
Your entire care team is connected electronically, so they can easily access your records and work together. You can manage your care online, including prescriptions, scheduling appointments, viewing lab results, and emailing your doctor’s office, all from the convenience of your home.
2025 Annual Notice of Change Updates
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Annual |
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| Deductible |
None |
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| Annual Out-of-Pocket Maximum – Medical |
$1,000 |
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| Annual Out-of-Pocket Maximum – Rx |
$2,000 |
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Physician Services |
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| Primary Care or Specialist Office Visit |
$20 |
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| Annual Wellness Visit / Routine PhysicalEye or Hearing ExamUrgent Care Consultations, Exams, & Treatments
Physical, Occupational, and Speech Therapy |
$0 $20 $20 $20 |
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Outpatient Care |
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| Outpatient Surgery |
$20 |
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| Allergy Injections |
$3 |
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| Most Immunizations |
No Charge |
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| Most X-rays, Annual Mammograms, and Lab Tests |
No Charge |
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| Manual Manipulation of Spine |
$20 |
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Hospitalization Services |
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| Room & Board, Surgery, Anesthesia, X-rays, Labs & Drugs |
No Charge |
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Home Health Services |
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| Home Health Care (part-time, intermittent) |
No Charge |
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Prescription Drug Co-Pay |
1-30 Day Supply |
31-60 Day Supply |
61 – 100 Day Supply |
| Most Generic at Plan PharmacyMost Generic via Mail OrderMost Brand at Plan Pharmacy
Most Brand via Mail Order |
$10 $10 $20 $20 |
$20 $20 $40 $40 |
$30 $20 $60 $40 |
| Specialty Drugs |
20% Co-Pay, up to $150 Maximum |
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Emergency Health Coverage |
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| Emergency Department Visits |
$50 |
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| Ambulance Services |
No Charge |
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Mental Health Services |
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| Inpatient Psychiatric Care |
No Charge |
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| Individual Outpatient Mental Health |
$20 |
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| Group Outpatient Mental Health Treatment |
$10 |
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Chemical Dependency Services |
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| Inpatient Detoxification |
No Charge |
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| Individual Outpatient Chemical Dependency |
$20 |
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| Group Outpatient Chemical Dependency Treatment |
$5 |
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Additional Services |
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| 1 Pass Fitness Program |
Included |
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| Eyewear Purchased at Plan Offices or Optical Sales |
$150 Allowance per 24 months |
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| Skilled Nursing Facility Care (100 days max) |
No Charge |
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| Covered Durable Medical Equipment for Home Use |
No Charge |
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| External Prosthetic and Orthotic Devices |
No Charge |
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| Post-discharge Meal Delivery Program |
Included |
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| Routine Medical Transportation (24 trips max) |
$0 |
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| Ostomy and Urological Supplies |
No Charge |
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The above is a summary of plan benefits and not a comprehensive list. While believed accurate, nothing listed above can change or alter the Certificate of Insurance.