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Kaiser Permanente Senior Advantage Core DM (HMO)

H0630 - 013 - 0

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Kaiser Permanente Senior Advantage Core DM (HMO) is a Medicare Advantage Plan by Kaiser Permanente.

This page features plan details for 2025 Kaiser Permanente Senior Advantage Core DM (HMO) H0630 – 013 – 0 available in Denver Metro Area.

Locations

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

Insurer:	Kaiser Permanente
Health Plan Deductible:	$0
MOOP:	$3,300 In-network
Drugs Covered:	Yes

Ready to sign up for Kaiser Permanente Senior Advantage Core DM (HMO) ?

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

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

Kaiser Permanente Senior Advantage Core DM (HMO) qualifies for a monthly Medicare Give Back Benefit of $10.00.

Premium Reduction:

$10.00

Premium Breakdown

Kaiser Permanente Senior Advantage Core DM (HMO) 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	$10.00	$

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 Core DM (HMO) 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 D	LIS 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.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$15.00 Copay
2) Generic	$3.00 Copay	$20.00 Copay
3) Preferred Brand	$45.00 Copay	$47.00 Copay	$45.00 Copay
4) Non-Preferred Drug	$90.00 Copay	$100.00 Copay	$90.00 Copay
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance
6) Vaccines

60 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$30.00 Copay
2) Generic	$6.00 Copay	$40.00 Copay
3) Preferred Brand	$90.00 Copay	$94.00 Copay	$90.00 Copay
4) Non-Preferred Drug	$180.00 Copay	$200.00 Copay	$180.00 Copay
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance
6) Vaccines

90 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$45.00 Copay
2) Generic	$9.00 Copay	$60.00 Copay
3) Preferred Brand	$135.00 Copay	$141.00 Copay	$135.00 Copay
4) Non-Preferred Drug	$270.00 Copay	$300.00 Copay	$270.00 Copay
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance
6) Vaccines

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 Core DM (HMO) also provides the following benefits.

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

- In-Network: Yes, contact plan for further details

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

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI)
- $40-90 copay (Authorization Required, Referral Required)
Lab services
- $0 copay (Authorization Required, Referral Required)
Diagnostic tests and procedures
- $0 copay (Authorization Required, Referral Required)
Outpatient x-rays
- $0 copay (Authorization Required, Referral Required)

Doctor visits

Specialist
- $15 copay per visit (Referral Required)
Primary
- $0 copay

Emergency care/Urgent care

Emergency
- $140 copay per visit (always covered)
Urgent care
- $25 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $15 copay (Referral Required)
Routine foot care
- $0 copay (Limits Apply, Referral Required)

Ground ambulance

- $290 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $0 copay
Hearing aids
- $0 copay (Limits Apply, Referral Required)
Fitting/evaluation
- $0 copay

Inpatient hospital coverage

- $195 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)

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

- $3,300 In-network

Medical equipment/supplies

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

Medicare Part B drugs

Chemotherapy
- $3-47 copay or 0-20% coinsurance (Authorization Required)
Other Part B drugs
- $3-47 copay or 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient group therapy visit with a psychiatrist
- $5 copay
Outpatient group therapy visit
- $5 copay
Outpatient individual therapy visit with a psychiatrist
- $10 copay
Inpatient hospital – psychiatric
- $195 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required, Referral Required)
Outpatient individual therapy visit
- $10 copay

Optional supplemental benefits

- Yes

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $180 copay per visit (Authorization Required, Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $10 copay (Referral Required)
Occupational therapy visit
- $10 copay (Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $203 per day for days 21 through 39
  $0 per day for days 40 through 100 (Authorization Required, Referral Required)

Transportation

- $0 copay (Limits Apply)

Vision

Contact lenses
- $0 copay (Limits Apply)
Eyeglass lenses
- $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Eyeglass frames
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $0 copay

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

- Covered

Advantage Plus Option 2

Acupuncture

Acupuncture
- Monthly Premium: $14.00

Hearing Aids

Prescription Hearing Aids (all types)
- Monthly Premium: $14.00

Preventive and Other Defined Supplemental Services

In-Home Support Services
- Monthly Premium: $14.00

Transportation Services

Transportation Services – Plan Approved Health-related Location
- Monthly Premium: $14.00