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Kaiser Permanente Senior Advantage Choice DM (PPO)

H3138 - 001 - 0
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Kaiser Permanente Senior Advantage Choice DM (PPO) is a Medicare Advantage Plan by Kaiser Permanente.

This page features plan details for 2025 Kaiser Permanente Senior Advantage Choice DM (PPO) H3138 – 001 – 0 available in Denver Metro Area.

Locations

Kaiser Permanente Senior Advantage Choice DM (PPO) is offered in the following locations.

Adams County, Colorado
Arapahoe County, Colorado
Boulder County, Colorado

Click to see more locations

Plan Overview

Kaiser Permanente Senior Advantage Choice DM (PPO) offers the following coverage and cost-sharing.

Insurer:Kaiser Permanente
Health Plan Deductible:$0
MOOP:$8,950 In and Out-of-network
$5,100 In-network
Drugs Covered:Yes

Ready to sign up for Kaiser Permanente Senior Advantage Choice DM (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Kaiser Permanente Senior Advantage Choice DM (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Kaiser Permanente Senior Advantage Choice DM (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Kaiser Permanente Senior Advantage Choice DM (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Endodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Implant Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 30 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $50-130 copay (Authorization Required, Referral Required)
  • Lab services
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required, Referral Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required, Referral Required)
  • Outpatient x-rays
    • In-Network: $15 copay (Authorization Required, Referral Required)
    • Out-of-Network: 40% coinsurance (Authorization Required, Referral Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $35 copay per visit
  • Specialist
    • Out-of-Network: $65 copay per visit
    • In-Network: $30 copay per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $35 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $30 copay (Referral Required)
    • Out-of-Network: $65 copay (Referral Required)

Ground ambulance

    • In-Network: $340 copay
    • Out-of-Network: $340 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • In-Network: $0 copay (Limits Apply, Referral Required)
    • Out-of-Network: $0 copay (Limits Apply, Referral Required)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 40% coinsurance
  • Fitting/evaluation
    • Out-of-Network: 40% coinsurance
    • In-Network: $0 copay
  • Medicare-Covered Hearing Exam
    • In-Network: $10 copay

Inpatient hospital coverage

    • In-Network: $295 per day for days 1 through 5
      $0 per day for days 6 through 90
      $0 per day for days 91 and beyond (Authorization Required, Referral Required)
    • Out-of-Network: $500 per day for days 1 through 18
      $0 per day for days 19 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $5,100 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 0-40% coinsurance per item (Authorization Required)
    • In-Network: $0 copay per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: $35 copay or 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: $35 copay or 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $15 copay
    • Out-of-Network: $40-50 copay
  • Inpatient hospital – psychiatric
    • Out-of-Network: $500 per day for days 1 through 18
      $0 per day for days 19 through 90 (Authorization Required, Referral Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $40-50 copay
  • Inpatient hospital – psychiatric
    • In-Network: $295 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required, Referral Required)
  • Outpatient group therapy visit
    • In-Network: $15 copay
    • Out-of-Network: $40-50 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $25 copay
  • Outpatient individual therapy visit
    • In-Network: $25 copay
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $40-50 copay

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $250 copay per visit (Authorization Required, Referral Required)
    • Out-of-Network: 40% coinsurance per visit (Authorization Required, Referral Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: 40% coinsurance (Referral Required)
    • In-Network: $30 copay (Referral Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 40% coinsurance (Referral Required)
    • In-Network: $30 copay (Referral Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $203 per day for days 21 through 46
      $0 per day for days 47 through 100 (Authorization Required, Referral Required)
    • Out-of-Network: $225 per day for days 1 through 40
      $0 per day for days 41 through 100 (Authorization Required, Referral Required)

Transportation

    • Out-of-Network: $0 copay (Limits Apply)
    • In-Network: $0 copay (Limits Apply)

Vision

  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay
  • Upgrades
    • Not covered
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: 40% coinsurance

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Advantage Plus PPO

Comprehensive Dental

  • Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
    • Monthly Premium: $41.00

Preventive and Other Defined Supplemental Services

  • In-Home Support Services
    • Monthly Premium: $41.00

Transportation Services

  • Transportation Services – Plan Approved Health-related Location
    • Monthly Premium: $41.00

Ready to sign up for Kaiser Permanente Senior Advantage Choice DM (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Kaiser Permanente Senior Advantage Choice DM (PPO)? See 2025 Kaiser Permanente Senior Advantage Choice DM (PPO) at MedicareAdvantageRX.com.

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