Overview
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Early Retirees who elect Kaiser have the same hospital and medical benefits as active participants. (See the Active Health BenefitTab for Kaiser.) Prescription drugs must be obtained only from Kaiser pharmacies. Please refer to the description provided below.
Participants on Medicare Parts A & B who elect the Kaiser Senior Advantage program have benefits, including prescription coverage, as described below.
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Annual Out-of-Pocket Maximum
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Description |
You Pay |
| For one Member |
$1,500 per calendar year |
| For an entire Family Unit |
$3,000 per calendar year |
| Deductible or Lifetime Maximum |
None. |
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Professional Services (Plan Provider office visits)
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Description |
You Pay |
| Primary and specialty care visits (includes routine and urgent care appointments) |
$5 per visit |
| Routine physical exams |
$5 per visit |
| Family planning visits |
$5 per visit |
| Scheduled prenatal care and first postpartum visit |
$5 per visit |
| Eye exams and glaucoma screening |
$5 per visit |
| Hearing tests |
$5 per visit |
| Physical, occupational, and speech therapy outpatient visits |
$5 per visit |
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Outpatient Services
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Description |
You Pay |
| Outpatient surgery |
$5 per procedure |
| Allergy injection visits |
No charge |
| Allergy testing visit |
$5 per visit |
| Immunizations |
No charge |
| X-rays, annual mammograms, and lab tests |
No charge |
| Manual Manipulation of the Spine |
$5 per visit |
| Health education |
$5 per individual visit. No charge for group visits. |
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Hospitalization Services
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| Room and board, surgery, anesthesia, X-rays, lab tests, and drugs |
No charge |
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Emergency Health Coverage
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| Emergency Department and Out-of-Area Urgent Care visits |
$5 per visit (waived if you are held for observation in a hospital unit outside the Emergency Department or if admitted to the hospital as an inpatient within 24 hours for the same condition) |
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Ambulance Services
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| Ambulance Services |
No charge |
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Prescription Drug Coverage
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Most covered outpatient items in accord with our drug formulary when obtained at Plan Pharmacies:
Generic items - $5 for up to a 100-day supply
Brand name items - $15 for up to a 100-day supply
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Durable Medical Equipment
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| Covered durable medical equipment for home use in accord with our DME formulary |
No charge |
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Mental Health Services
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| Description |
You Pay |
| Inpatient psychiatric care: first 190 days per lifetime as covered by Medicare. Thereafter, up to 45 days per calendar year |
No charge |
| Outpatient visits: Individual and group therapy visits |
$5 per individual therapy visit
$2 per group therapy visit |
Note: Visit and day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage. |
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Chemical Dependency Services
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| Description |
You Pay |
| Inpatient detoxification |
No charge |
| Outpatient individual therapy visits |
$5 per visit |
| Outpatient group therapy visits |
$2 per visit |
| Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) |
$100 per admission |
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Home Health Services
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| Home health care (part-time, intermittent) |
No charge |
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Other
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| Description |
You Pay |
| Eyewear purchased from Plan optical sales offices every 24 months |
$150 Allowance |
| Chiropractic Care 30 office visits per year |
$5 per visit |
| Skilled nursing facility care (up to 100 days per benefit period) |
No charge |
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