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An HMO with a Medicare Contract Including Prescription Drug Coverage
Kaiser Permanente Senior Advantage is a division of Kaiser Permanente who owns its hospitals and clinics and contracts with Southern California Permanente Medical Group to provide staff at these hospitals and clinics. If you live within the Enrollment Area at the time of enrollment and meet eligibility requirements, you and your spouse may enroll in Kaiser Permanente Senior Advantage.

When you join Kaiser Permanente Senior Advantage, to receive covered benefits, you must select a Kaiser Permanente physician and facility to provide care for you and your spouse. You are not restricted to the use of just one Kaiser Permanente physician or facility, but you are encouraged to select and use the one facility that will be convenient to you.

Kaiser Permanente Senior Advantage Plan benefits apply only when the services are medically necessary, prescribed, or directed by a Kaiser Permanente physician except where specifically stated in “Emergency Services.”

With each office of emergency visit, you will need to present your Kaiser Permanente ID card to the receptionist.

Principal Benefits for Kaiser Permanente Senior Advantage
The Services described below are covered only if all the following conditions are satisfied:

• The Services are Medically Necessary
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Service Area, except where specifically noted to the contrary for authorized referrals, Emergency Care, Post-stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services described in the Evidence of Coverage

Annual Out-of-Pocket Maximum
For one Member	$1,500 per calendar year
For an entire Family Unit	$3,000 per calendar year

Deductible or Lifetime Maximum

None

Professional Services (Plan Provider office visits)	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 visits	$5 per visit

Outpatient Services	You Pay
Outpatient surgery	$5 per procedure
Allergy injection visits	No charge
Allergy testing visits	$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

Hospitalization Services	You Pay
Room and board, surgery, anesthesia, X-rays, lab tests, and drugs	No charge

Emergency Health Coverage	You Pay
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)

Ambulance Services	You Pay
Ambulance Services	No charge

Prescription Drug Coverage	You Pay
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

Durable Medical Equipment	You Pay
Covered durable medical equipment for home use in accord with our DME formulary	No charge

Mental Health Services	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.

Chemical Dependency Services	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

Home Health Services	You Pay
Home health care (part-time, intermittent)	No charge

Other	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

This is a brief summary of the most frequently asked about benefits and their Co-payments and Coinsurance. This chart does not describe benefits and it does not list all benefits, Co-payments, and Coinsurance. Please refer to the Evidence of Coverage to learn about coverage (including exclusions and limitations) and other benefits, Co-payments, and Coinsurance that are not included in this summary. Note: We cover benefits in accord with applicable law (for example, diabetes supplies).