Kaiser Permanente Senior Advantage Value Lane (HMO-POS)

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

• • In-Network: No

Diagnostic procedures/lab services/imaging

• Diagnostic tests and procedures
  • In-Network: $10-30 copay (Authorization Required, Referral Required)
  • Out-of-Network: $0-25 copay (Authorization Required, Referral Required)
• Lab services
  • Out-of-Network: $0-25 copay (Authorization Required, Referral Required)
• Outpatient x-rays
  • In-Network: $10 copay (Authorization Required, Referral Required)
• Diagnostic radiology services (e.g., MRI)
  • In-Network: $10-350 copay (Authorization Required, Referral Required)
  • Out-of-Network: $0-25 copay (Authorization Required, Referral Required)
• Lab services
  • In-Network: $0 copay (Authorization Required, Referral Required)
• Outpatient x-rays
  • Out-of-Network: $0-25 copay (Authorization Required, Referral Required)

Doctor visits

• Specialist
  • In-Network: $30 copay per visit (Authorization Required, Referral Required)
• Primary
  • Out-of-Network: $0-55 copay per visit
  • In-Network: $5 copay per visit
• Specialist
  • Out-of-Network: $0-55 copay per visit (Authorization Required, Referral Required)

Emergency care/Urgent care

• Urgent care
  • $65 copay per visit (always covered)
• Emergency
  • $140 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • Out-of-Network: $0-55 copay (Authorization Required, Referral Required)
  • In-Network: $30 copay (Authorization Required, Referral Required)
• Routine foot care
  • Not covered

Ground ambulance

• • In-Network: $350 copay

Health plan deductible

• • $0

Hearing

• Hearing aids – outer ear
  • Not covered
• Hearing aids – over the ear
  • Not covered
• Fitting/evaluation
  • Not covered
• Hearing aids – inner ear
  • Not covered
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • In-Network: $30 copay
  • Out-of-Network: $0-55 copay

Inpatient hospital coverage

• • In-Network: $450 per day for days 1 through 4
    $0 per day for days 5 through 90
    $0 per day for days 91 and beyond (Authorization Required, Referral Required)
  • Out-of-Network: Not Applicable (Authorization Required, Referral Required)

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

• • $3,800 In-network

Medical equipment/supplies

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

Medicare Part B drugs

• Other Part B drugs
  • In-Network: $0-47 copay or 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 0-20% coinsurance (Authorization Required)
• Chemotherapy
  • In-Network: $10-47 copay or 0-20% coinsurance (Authorization Required)
  • Out-of-Network: 0-20% coinsurance (Authorization Required)

Mental health services

• Outpatient individual therapy visit
  • In-Network: $5 copay (Authorization Required)
• Inpatient hospital – psychiatric
  • Out-of-Network: Not Applicable (Authorization Required, Referral Required)
• Outpatient group therapy visit
  • In-Network: $2 copay (Authorization Required)
  • Out-of-Network: $0-55 copay (Authorization Required)
• Outpatient individual therapy visit
  • Out-of-Network: $0-55 copay (Authorization Required)
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $5 copay (Authorization Required)
• Inpatient hospital – psychiatric
  • In-Network: $450 per day for days 1 through 4
    $0 per day for days 5 through 90 (Authorization Required, Referral Required)
• Outpatient group therapy visit with a psychiatrist
  • In-Network: $2 copay (Authorization Required)

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • In-Network: $0-300 copay per visit (Authorization Required, Referral Required)

Preventive care

• • In-Network: $0 copay
  • Out-of-Network: $0-55 copay

Rehabilitation services

• Occupational therapy visit
  • In-Network: $35 copay (Authorization Required, Referral Required)
  • Out-of-Network: $0-55 copay (Authorization Required, Referral Required)
• Physical therapy and speech and language therapy visit
  • In-Network: $35 copay (Authorization Required, Referral Required)
  • Out-of-Network: $0-55 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

• • Out-of-Network: Not Applicable (Authorization Required, Referral Required)
  • In-Network: $0 per day for days 1 through 20
    $196 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

• • Not covered

Vision

• Eyeglass frames
  • Not covered
• Eyeglass lenses
  • Not covered
• Other
  • Not covered
• Routine eye exam
  • In-Network: $30 copay
• Contact lenses
  • Not covered
• Eyeglasses (frames and lenses)
  • Not covered
• Upgrades
  • Not covered

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

• • Covered (Authorization Required, Referral Required)

Advantage Plus

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $46.00

Diagnostic and Preventive Dental

• Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services
  • Monthly Premium: $46.00

Eyewear

• Contact Lenses, Eyeglasses (lenses and frames), Eyeglass lenses, Eyeglass frames, Upgrades
  • Monthly Premium: $46.00

Hearing Aids

• Prescription Hearing Aids (all types)
  • Monthly Premium: $46.00

Hearing Exams

• Fitting/Evaluation for Hearing Aid
  • Monthly Premium: $46.00