Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP)
H0524 - 073 - 0
(5 / 5)
Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Kaiser Permanente.
This page features plan details for 2023 Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) H0524 – 073 – 0 available in Medicare Medi-Cal Inland Empire Plan.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) is offered in the following locations.
Plan Overview
Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | Kaiser Permanente |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
Ready to sign up for Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) ?
Premium Breakdown
Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) has a monthly premium of $29.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $29.00 | $0.00 | $193.90 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $505.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $29.00 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $505.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (no limits) (authorization required) (referral required) |
| Endodontics: | $0 copay (no limits) (authorization required) (referral required) |
| Extractions: | $0 copay (no limits) (authorization required) (referral required) |
| Non-routine services: | $0 copay (no limits) (authorization required) (referral required) |
| Periodontics: | $0 copay (no limits) (authorization required) (referral required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (no limits) (authorization required) (referral required) |
| Restorative services: | $0 copay (no limits) (authorization required) (referral required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral required) |
| Dental x-ray(s): | $0 copay (no limits) (authorization not required) (referral required) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | $0 copay (no limits) (authorization not required) (referral required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0 copay (authorization not required) (referral required) |
| Diagnostic tests and procedures: | $0 copay (authorization not required) (referral required) |
| Lab services: | $0 copay (authorization not required) (referral required) |
| Outpatient x-rays: | $0 copay (authorization not required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization not required) (referral required) |
Emergency care/Urgent care
| Emergency: | $0 copay |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $0 copay (authorization not required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $0 or $200 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | $0 copay (authorization not required) (referral required) |
Hospital coverage (inpatient)
| $0 copay (authorization required) (referral required) |
Hospital coverage (outpatient)
| $0 copay (authorization not required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $3,400 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0% or 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | $0 copay (authorization required) |
Medicare Part B drugs
| Chemotherapy: | $0 copay (authorization required) |
| Other Part B drugs: | $0 copay (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $0 copay (authorization not required) (referral required) |
| Outpatient group therapy visit: | $0 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | $0 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization not required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral required) |
Rehabilitation services
| Occupational therapy visit: | $0 copay (authorization not required) (referral required) |
| Physical therapy and speech and language therapy visit: | $0 copay (authorization not required) (referral required) |
Skilled Nursing Facility
| $0 copay (authorization required) (referral required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (no limits) (authorization not required) (referral required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral required) |
Ready to sign up for Senior Advantage Medicare Medi-Cal Inland Empire (HMO D-SNP) ?