2026 Kaiser Permanente Senior Advantage HI (HMO)
2026 Kaiser Permanente Senior Advantage HI (HMO) Plan Details
Group # 45041-5
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.
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 Kaiser plan is not available in all zip codes in the state of Hawaii. Please contact Kaiser or the Stanford UHR Service Center if you have questions about your home zip code.
This document is a summary. Please refer to the plan Evidence of Coverage (EOC) *coming soon* for more details.
Basics
Deductible:
No deductible
Office co-pay:
Primary $30 copay
Specialist $40 copay
Specialist $40 copay
Coinsurance:
100% after applicable copays
Out-of-Pocket Maximum:
$3,000 per individual/ 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.
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.
Overall Lifetime Maximum Benefit:
No maximum
Maternity
Maternity Hospital Stay:
$500 per admission
Baby's First Exam:
Not covered unless eligible for Medicare due to ESRD; if eligible, $0-$30 per visit depending on type of visit.
Birthing Centers:
$500 per admission when approved by Plan physician
Midwives:
100% (Included in hospital admission cost share); $30 outpatient office visit
Prenatal and Postnatal Physician Office Visits:
100%
Doctor Delivery Charge:
100%
Reproductive Health:
$30 copay
Mental Health/Autism/Substance Abuse
Mental Health:
$30 includes opioid treatment program
Substance Abuse:
$30 includes opioid treatment program
Prescription Drugs
Pharmacy (Retail):
KAISER PERMANENTE PHARMACY
Generic: $15 for up to a 30-day supply, $30 for a 31- to 60-day supply, or $45 for a 61- to 100-day supply
Preferred 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
Non-Preferred Brand: $35 for up to a 30-day supply, $70 for a 31- to 60-day supply, or $105 for a 61- to 100-day supply
Specialty: $100 for up to a 30-day supply, $200 for a 31- to 60-day supply, or $300 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: $15 for up to a 30-day supply, $30 for a 31- to 60-day supply, or $45 for a 61- to 100-day supply
Preferred 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
Non-Preferred Brand: $35 for up to a 30-day supply, $70 for a 31- to 60-day supply, or $105 for a 61- to 100-day supply
Specialty: $100 for up to a 30-day supply, $200 for a 31- to 60-day supply, or $300 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:
Mail-order (61-100 day supply)
Generic $30
Preffered Brand $60
Non-Preferred Brand $70
Generic $30
Preffered Brand $60
Non-Preferred Brand $70
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:
$20 per visit up to 20 visits combined acupuncture and chiropractic visits per year
Allergy Tests:
$30 copay
Allergy Treatment:
$40 copay
Alternative Medicine:
Not covered
Ambulance charges:
$100 copay
Benefit Perks:
See Kaiser Senior Advantage OnePass exercise program flyer on Cardinal at Work or call 877-427-4788.
CT and PET Scans (Complex Imaging):
$20 copay
Chiropractors:
$20 per visit up to 20 visits combined acupuncture and chiropractic visits per year
Christian Science Practitioners:
Not covered
Cosmetic Surgery:
Not covered
Dental Treatment:
Not covered
Emergency Room:
$100 copay (waived if admitted)
Urgent Care:
$30 copay per visit
Hearing Care:
100% for routine exam during annual physical. Audiologist hearing exam $30 copay, Specialist visit to diagnose and treat hearing problems $30 copay.
Home Health Care:
100%
Hospice Care:
100%
Hospital Stay:
$500 copay per admission
Infertility Treatment:
$30 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):
$20 copay
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:
20% Coinsurance
Occupational Therapy:
$30 copay
Organ Transplants:
Contact Kaiser Permanente for information on transplant coverage benefits
Skilled Nursing:
100% Up to 100 days per benefit period
Physical Therapy:
$30 copay
Surgery : Facility Charges:
INPATIENT
$500 per admission
OUTPATIENT
$100 copay
$500 per admission
OUTPATIENT
$100 copay
Surgery : Physician Services:
INPATIENT
$500 copay per admission
OUTPATIENT
$100 copay
$500 copay per admission
OUTPATIENT
$100 copay
Transgender Services:
See Kaiser for details
Transportation:
Not Covered
Travel and Lodging:
Contact the plan for details
Vasectomy:
$30 copay
Vision care:
$30 eye exam; 20% post-cataract surgery eyewear in accordance with Medicare guidelines; all others not covered
X-rays (Basic Imaging):
$20 copay