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Footnotes
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Dental benefits are underwritten by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., and administered by LIBERTY Dental Plan.
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With a 50% coinsurance. Annual allowance varies by plan type. See your Evidence of Coverage for details.
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One Pass® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions and is a voluntary program.
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Please refer to your Evidence of Coverage for details. OTC benefits may change each year on January 1. Each order must be at least $20. Any unused portion of the quarterly benefit limit will not carry forward to the next quarter. Your order may not exceed your quarterly benefit limit. Limitations and restrictions may apply. Cash, check, credits cards, or money orders are not accepted.
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Hearing aid allowance can only be used for hearing aids purchased at Kaiser Permanente audiology centers.
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Twenty-four one-way rides per contract year. For nonemergency transportation only. Transportation benefits are not available with the following plans: Kaiser Permanente Medicare Advantage Value Balt (HMO), Kaiser Permanente Medicare Advantage Value MD (HMO), Kaiser Permanente Medicare Advantage Value DC (HMO-POS), Kaiser Permanente Medicare Advantage Liberty (HMO), and Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS).
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Not available with Kaiser Permanente Medicare Advantage Care Plus VA (HMO-POS), Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS), Kaiser Permanente Medicare Advantage Value Baltimore (HMO), Kaiser Permanente Medicare Advantage Value MD (HMO), and Kaiser Permanente Medicare Advantage Liberty (HMO) plans. Members are responsible for any charged amounts for covered services that exceed the annual allowance maximum of $1,200. Coverage limited to inside the United States and its territories. See your Evidence of Coverage for details.
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If you get care at a MinuteClinic® or Concentra Urgent Care in states without Kaiser Permanente, you’ll be charged your standard copay or coinsurance. If you get urgent care at a MinuteClinic®, Concentra Urgent Care, or any other urgent care facility in a state with Kaiser Permanente providers, you’ll be asked to pay upfront for services you receive and will need to file a claim for reimbursement.
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When receiving care at a Kaiser Permanente facility. Some prescriptions are not available through the mail-order pharmacy.
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May vary by plan type. Check your plan benefits for more information. For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-order pharmacy. You should receive them within 3–5 days. If not, please call 1-800-733-6345.
Kaiser Permanente is an HMO and HMO-POS plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.
The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the grievance process.
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