Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP)
H1170 - 008 - 0
(3.5 / 5)
Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) is a Medicare Advantage Special Needs Plan by Kaiser Permanente.
This page features plan details for 2024 Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) H1170 – 008 – 0 available in Atlanta Metro Area.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) is offered in the following locations.
Plan Overview
Senior Advantage Medicare Medicaid Plan 1 (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: | $1,000 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.
- This plan does not charge an annual deductible for all drugs. The $545 annual deductible only applies to drugs on certain tiers.
- 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 Medicaid Plan 1 (HMO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) has a monthly premium of $42.30. 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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $42.30 | $0.00 | $ |
- 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 Medicaid Plan 1 (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced |
| Additional 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 Full |
|---|---|
| $42.30 | $0.00 |
Initial Coverage Phase
After you pay your $545.00 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 $5,030.00. 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 |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $14.00 copay | $14.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 25% | 25% | ||
| 6 (Vaccines ($0 cost sharing)) | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Vaccines ($0 cost sharing)) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $42.00 copay | $0.00 copay | ||
| 3 (Preferred Brand) | $141.00 copay | $94.00 copay | ||
| 4 (Non-Preferred Drug) | $300.00 copay | $200.00 copay | ||
| 5 (Specialty Tier) | 25% | 25% | ||
| 6 (Vaccines ($0 cost sharing)) |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced benefit type.
Additional Benefits
Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) also provides the following benefits.
| $0 |
| In-network | No |
| $1,000 In-network |
| Yes |
| In-network | Yes, contact plan for further details |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0 copay (Authorization is not required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $0 or $20 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Restorative services | $28-580 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | $0-400 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Extractions | $22 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0-480 copay or 75% coinsurance (There are no limits.) (Authorization is required.) (Referral is required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $0 copay (Authorization is not required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is required.) |
| $0 or $25 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | $0 or $0-47 copay (Authorization is required.) (Not applicable.) |
| Other Part B drugs | $0 or $0-47 copay (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $0 or $0-35 copay (Authorization is required.) (Not applicable.) |
| $0 or $12 per stay $0 per day for days 90 and beyond (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $0 or $12 per stay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 100 (Authorization is required.) (Referral is required.) |
| Monthly Premium | $9.00 |
| Deductible | nan |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $9.00 |
| Comprehensive dental: | Deductible: | N/A |
| Hearing exam: | Monthly Premium: | $9.00 |
| Hearing exam: | Deductible: | N/A |
| Hearing aids: | Monthly Premium: | $9.00 |
| Hearing aids: | Deductible: | N/A |
Ready to sign up for Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Table of Contents
Need more information on Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP)? See 2025 Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP) at MedicareAdvantageRX.com.
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