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Kaiser Permanente Dual Complete South P5 (HMO D-SNP) - H8794-005-000

Plan too new to be measured* for plan year 2025

$0.00

Monthly Premium

Kaiser Permanente Dual Complete South P5 (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H8794-005-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

California Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about California Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$590.00
Out-of-pocket maximum$3,400.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Referral Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$0 per day for days 1 to 90
Referral Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Emergency room visit
Emergency Care:
Copayment for Emergency Care $0
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0
Copayment for Worldwide Emergency Transportation $0
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0

Air Ambulance:
Copayment for Air Ambulance Services $0

Health Care Services and Medical Supplies

Kaiser Permanente Dual Complete South P5 (HMO D-SNP) covers a range of additional benefits. Learn more about Kaiser Permanente Dual Complete South P5 (HMO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment
The minimum coinsurance applies to peak flow meters and ultraviolet light therapy equipment for psoriasis treatment. The maximum coinsurance applies to all other DME.
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Referral Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$0 per day for days 1 to 90
Referral Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $200.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $200 every three months
OTC items: We cover OTC items listed in our OTC catalog for free home delivery. Each order must be at least $25. NRT: We cover FDA-approved nicotine replacement therapy over-the-counter medications up to two 100-day supplies during the calendar year.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Referral Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $0
Prior Authorization Required for Medicare Covered Preventive Dental
Referral Required for Medicare Covered Preventive Dental

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0
Maximum Plan Allowance of $350 every year
Referral Required for Eyewear

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Kaiser Permanente Dual Complete South P5 (HMO D-SNP) offers prescription drug coverage, with an annual drug deductible of $590.00 (excludes Tiers 1, 2, and 6)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$590.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 2
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 6
    • Standard retail $0.00
    Annual drug deductible$590.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 2
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 6
    • Standard retail N/A
    Annual drug deductible$590.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 2
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 6
    • Standard retail N/A

    When reviewing California Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of California that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    California Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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