2026 Kaiser Permanente Senior Advantage CA (HMO)
2026 Kaiser Permanente Senior Advantage CA (HMO) Plan Details
Group #: 7145-3 (Northern CA), Group #: 230178-3 (Southern CA)
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) * coming soon * for more details.
Basics
Deductible:
No deductible
Coinsurance:
100% after applicable copays
Out-of-Pocket Maximum:
$1,000 per individual
$2,000 family
Prescription copays do not accumulate towards the medical $1,000/$2,000 max
$1,000 per individual
$2,000 family
Prescription copays do not accumulate towards the medical $1,000/$2,000 max
Pharmacy Part D max out-of-pocket of $2,100
You pay copays during the Initial Coverage Stage until your out-of-pocket prescription costs reach $2,100 in 2026. After that, you move to the Catastrophic Stage, where you no longer pay copays for covered prescriptions for the rest of the year.
Please note: Prescription copays do not count toward the medical out-of-pocket maximum of $1,000/$2,000.
$2,000 family
Prescription copays do not accumulate towards the medical $1,000/$2,000 max
$1,000 per individual
$2,000 family
Prescription copays do not accumulate towards the medical $1,000/$2,000 max
Pharmacy Part D max out-of-pocket of $2,100
You pay copays during the Initial Coverage Stage until your out-of-pocket prescription costs reach $2,100 in 2026. After that, you move to the Catastrophic Stage, where you no longer pay copays for covered prescriptions for the rest of the year.
Please note: Prescription copays do not count toward the medical out-of-pocket maximum of $1,000/$2,000.
Overall Lifetime Maximum Benefit:
No maximum
Maternity
Maternity Hospital Stay:
100%
Baby's First Exam:
100%
Birthing Centers:
100% - When approved by a Plan Physician
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 and Postnatal Physician Office Visits:
100%
Doctor Delivery Charge:
100%
Reproductive Health:
$25 copay
Mental Health/Autism/Substance Abuse
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
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
Prescription Drugs
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
Pharmacy copayments will accumulate towards the CMS-required Part D max out-of-pocket of $2,100
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
Pharmacy copayments will accumulate towards the CMS-required Part D max out-of-pocket of $2,100
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.
Pharmacy copayments will accumulate towards the CMS-required Part D max out-of-pocket of $2,100
Retiree and dependent members can get over-the-counter health and wellness products delivered to their residence at no cost.
Pharmacy copayments will accumulate towards the CMS-required Part D max out-of-pocket of $2,100
Birth Control Pills:
Included in Prescription Drug benefit
Preventive Care
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%
Other Services
Acupuncture:
$15 copay per visit
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
Benefit Perks:
See Kaiser Senior Advantage OnePass exercise program flyer on Cardinal at Work or call 877-427-4788.
Kaiser Senior Advantage members receive a $70 quarterly allowance for over-the-counter health and wellness products and prescriptions. Additionally, following an inpatient stay at a hospital or skilled nursing facility, fresh, healthy meals can be delivered directly to their door at no cost.
The plan also includes transportation benefits, covering up to 24 one-way trips per calendar year (up to 50 miles per trip) to and from medical appointments.
For more details, please refer to Cardinal at Work.
Kaiser Senior Advantage members receive a $70 quarterly allowance for over-the-counter health and wellness products and prescriptions. Additionally, following an inpatient stay at a hospital or skilled nursing facility, fresh, healthy meals can be delivered directly to their door at no cost.
The plan also includes transportation benefits, covering up to 24 one-way trips per calendar year (up to 50 miles per trip) to and from medical appointments.
For more details, please refer to Cardinal at Work.
CT and PET Scans (Complex Imaging):
100%
Chiropractors:
$15 copay per visit
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/per visit copay (waived if admitted)
Urgent Care:
$25 copay/per visit
Hearing Care:
100% for routine exam during annual physical. Audiologist hearing exam $25 copay, Specialist visit to diagnose and treat hearing problems $25 copay.
Hearing aids covered at $3,000 per ear every 36 months
Hearing aids covered at $3,000 per ear every 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) (Complex Imaging):
100%
Meals:
Senior Advantage members are eligible to receive up to 84 fresh, healthy meals delivered to their home at no cost, immediately following an inpatient stay at a hospital or skilled nursing facility.
Durable Medical Equipment:
100%
Occupational Therapy:
$25 copay per visit
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.
A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility,
receiving a skilled level of care, for 60 consecutive days
Up to 100 days per benefit period. More than 100 days not covered.
A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility,
receiving a skilled level of care, for 60 consecutive days
Physical Therapy:
$25 copay per visit
Surgery : Facility Charges:
INPATIENT
100%
OUTPATIENT
$25 copay per procedure
100%
OUTPATIENT
$25 copay per procedure
Surgery : Physician Services:
INPATIENT
100%
OUTPATIENT
100% after Facility Charge copay
100%
OUTPATIENT
100% after Facility Charge copay
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)
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.
Travel and Lodging:
Contact the plan for details
Vasectomy:
$25 copay per procedure
Vision care:
100%
$150 eyewear allowance every 24 months
Contact Kaiser Permanente for other vision benefit information
$150 eyewear allowance every 24 months
Contact Kaiser Permanente for other vision benefit information
X-rays (Basic Imaging):
100%