Footnotes
1. Dental benefits are underwritten by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., and administered by LIBERTY Dental Plan. Continue at [1]
2. With a 50% coinsurance. Annual allowance varies by plan type. Not available with Kaiser Permanente Medicare Advantage Value 2 MD (HMO). See your Evidence of Coverage for details. Continue at [2]
3. One Pass® is a registered trademark of One Pass Solutions, Inc. in the U.S. and other jurisdictions and is a voluntary program. Continue at [3]
4. Not available with Kaiser Permanente Medicare Advantage Value 2 MD (HMO) plan. Please refer to your Evidence of Coverage for details. OTC benefits may change each year on January 1. Any unused portion of the quarterly/monthly benefit limit will not carry forward to the next quarter or month. Any unused amounts are forfeited upon disenrollment from our plan. The cost of eligible OTC items will be covered up to the balance available on your card. If there is a remaining amount to pay, you must use another form of payment. Continue at [4]
5. Hearing aid allowance can only be used for hearing aids purchased at Kaiser Permanente audiology centers. Continue at [5]
6. Twenty-four one-way rides per contract year. For nonemergency transportation only. Not available with Kaiser Permanente Medicare Advantage Liberty (HMO), Kaiser Permanente Medicare Advantage Value 1 MD (HMO), Kaiser Permanente Medicare Advantage Value 2 MD (HMO), Kaiser Permanente Medicare Advantage Value DC (HMO-POS), and Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS) plans. Continue at [6]
7. Not available with Kaiser Permanente Medicare Advantage Care Plus VA (HMO-POS), Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS), and Kaiser Permanente Medicare Advantage Liberty (HMO), Kaiser Permanente Medicare Advantage Value 1 MD (HMO), and Kaiser Permanente Medicare Advantage Value 2 MD (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. Continue at [7]
8. 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. Continue at [8]
9. The Healthy Food benefit is part of a special supplemental program for the chronically ill. Not all members qualify. Members must have specific chronic conditions, like diabetes, chronic lung disorders, cardiovascular disorders, chronic heart failure, or cancer to be eligible. There are other conditions that may qualify you for the benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us. Continue at [9]
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.
Sign out
