kaiser retiree medical

If you live in Southern California, you can choose Kaiser HMO for Retirees, a plan available to retirees under age 65. The Kaiser Senior Advantage Plan is available to those over age 65 and Medicare-eligible.

Take a quick look at key features of the 2016 Kaiser retiree medical options.

plan features

	HMO (pre-65)	Senior Advantage Plan (Medicare-eligible)
	Network Only	Network Only
Annual Deductible	None	None
Out of-Pocket Maximum Individual Family	$1,500 $3,000	$1,500 $3,000

covered services

	HMO (pre-65)	Senior Advantage Plan (Medicare-eligible)
	Network Only	Network Only
	What You Pay
Preventive Services	$0 copay	$0 copay
Office Visits
Primary care	$30 copay Covered in full for prenatal and well baby care for 23 months or younger.	$10 copay
Specialist	$30 copay	$10 copay
Vision Care
Eye exam	$0 copay for refraction; $30 copay for treatment due to disease or injury	$0 copay for refraction; $10 copay for treatment due to disease or injury
Materials	Not covered	$150 allowance every 2 years
Outpatient
X-Ray and Lab work	$0 copay	$0 copay
Physical Therapy (Limited to medically necessary therapy with physician authorization)	$30 copay	$10 copay
Chiropractic Care	Not covered	Not covered
Inpatient Hospital
Room and board	$250 copay/admission	$200 copay/admission
Ancillary charges	Covered 100% after inpatient hospital copay	Covered 100% after inpatient hospital copay
Special Duty Nursing (For medically necessary care prescribed by physician)	Covered 100% after inpatient hospital copay	Covered 100% after inpatient hospital copay
Skilled Nursing Facility	Covered 100% up to 100 days/benefit period	Covered 100% up to 100 days/benefit period
Surgery
Inpatient	Covered 100% after inpatient hospital copay	Covered 100% after inpatient hospital copay
Outpatient	$30 copay/procedure	$10 copay/procedure
Alcohol and Chemical Dependency
Detoxification
Inpatient	$250 copay	$200 copay
Outpatient	$30 copay/individual visit $5 copay/group visit	$10 copay/individual visit
Rehabilitation
Inpatient	$100 copay for Transitional Residential Recovery Services	$200 copay for Transitional Residential Recovery Services
Outpatient	$30 copay/individual visit $5 copay/group visit	$10 copay/individual visit
Mental Health
Inpatient	$250 copay	$200 copay
Outpatient	$30 copay/individual visit; $15 copay/group visit	$10 copay/individual visit
Other Services
Hospice Care (in service area with physician authorization)	Covered 100%	Covered 100%
Home Health Care	Covered 100% up to 3 visits/day; 100 visits/year max.	Covered 100% up to 3 visits/day; 100 visits/year max.
Durable Medical Equipment	$0 copay	20%
Emergency Room	$100 copay/visit (waived if admitted)	$50 copay/visit (waived if admitted)
Ambulance	$0 copay	$50 copay

 

prescription drugs

Benefit
	HMO (pre-65)	Senior Advantage Plan (Medicare-eligible)
Out-of-Pocket (OOP) Drug Limit	Applies to medical plan OOP limit	Applies to medical plan OOP limit
Retail* (up to 30-day supply)	$15 Generic $35 Brand	$10 Generic $35 Brand
Mail Order* (up to 100-day supply)	$30 Generic $70 Brand	$20 Generic $70 Brand

* Mandatory formulary and generic requirement. Non-formulary drug is available if prescribed by physician.