Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO)
Kaiser Permanente · HMO · 2026 coverage
The big numbers
The plan premium is on top of your Part B premium.
- Monthly premium
- $95
- Higher than most plans here
- Most you pay in a year for covered care in network
- $3,900
- Higher than most plans here
- Drug deductible
- $0
- Most you pay for covered drugs in a year
- $2,100
- Medicare star rating
- 4.5 of 5
This plan serves only part of Santa Clara County. Check that it covers your ZIP code before you join.
In plain English
Compared with the 25 other plans in Santa Clara County that the same person could join.
What stands out
- No drug deductible
Watch out for
- $95 monthly premium, higher than most plans here
- Up to $3,900 a year for covered care, higher than most plans here
- $1,300 for a 5-day hospital stay, higher than most plans here
- $15 for specialist visits, higher than most plans here
What a year could cost
Premiums plus the plan’s copays for three example years. Medicines are not included.
- A light year$1,140$1,140 in premiums + $0 for careHigher than most plans here2 checkups and 2 lab tests.
- A busier year$1,200$1,140 in premiums + $60 for careHigher than most plans here4 checkups, 4 specialist visits, 4 lab tests, 1 X-ray and 1 urgent care visit.
- A hard year$3,620$1,140 in premiums + $2,480 for careHigher than most plans here6 checkups, 12 specialist visits, 6 lab tests, 2 scans, an ambulance ride, an ER visit and a 5-day hospital stay.Uses the highest listed cost for: MRI, CT and other scans.
The visit counts are examples we chose to show how costs add up, not a prediction. Your costs depend on the care you get.
What you pay for care
Your cost each time, at doctors and hospitals in the plan’s network.
- Primary care visit$0
- Specialist visit$15Higher than most plans hereReferral needed
- Urgent care$0
- Emergency room$150Tied for highest hereNot charged if you stay in the hospital within 24 hours
- Hospital stay$260 a day for days 1 to 5, then $0 for days 6 to 90Higher than most plans hereReferral neededPlan approval may be needed
- Lab tests$0Referral needed
More care: surgery, scans, mental health, therapy, home health and more
- Outpatient surgery center$260Higher than most plans here
- Outpatient hospital care$0 to $260Depends on the service
- X-rays$0Referral needed
- MRI, CT and other scans$0 to $275Depends on the serviceReferral needed
- Ground ambulance$300Tied for highest here
- Skilled nursing facility$0 for days 1 to 20, then $100 a day for days 21 to 100Referral needed
- Mental health therapy visit$0Tied for lowest here
- Psychiatrist visit$0Tied for lowest here
- Physical or speech therapy$0 to $10Depends on the serviceReferral needed
- Occupational therapy$5 to $10Depends on the serviceReferral needed
- Home health care$0Referral needed
- Medical equipment, like a walker or oxygen0% to 20%Depends on the servicePlan approval may be needed
- Kidney dialysis20%
- Chemotherapy and radiation drugs$0 to $47 or 0% to 20%Depends on the service
- Other drugs given at a clinic$0 to $47 or 0% to 20%Depends on the service
- Heart rehab$0 to $15Depends on the serviceReferral needed
- Foot doctor (podiatrist)$15Higher than most plans hereReferral needed
- Chiropractor$0Referral neededPlan approval may be needed
From the costs the plan filed with Medicare for 2026. A range like “$0 to $100” means the cost depends on the service or the place. “Lower than most” compares this plan with the 25 other plans in Santa Clara County that the same person could join. Read the plan’s 2026 booklet (PDF)
Is my doctor in this plan?
Look up your doctors, then confirm with their office.
Add your doctors once. We’ll check them against each plan you look at.
Before you choose, call each doctor’s office and ask:
“Do you take Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO), plan number H0524-039, for 2026?”
What medicines cost
The most you pay for covered drugs in 2026 is $2,100. After that, covered drugs cost $0 for the rest of the year.
| Drug tier | Network pharmacy |
|---|---|
| 1Preferred Generic | $0 |
| 2Generic | $7 |
| 3Preferred Brand | $47 |
| 4Non-Preferred Drug | $100 |
| 5Specialty Tier | 33% of the price |
| 6Vaccines | $0 |
For a 1-month supply. Covered insulin costs at most $35 for a month’s supply. Your medicine’s tier is on the plan’s drug list; check it below.
Check my medicines
See if this plan covers each medicine you take in 2026, and what a month costs.
Type the name on the bottle. Add the strength to narrow it down.
Add each medicine once. We’ll show if this plan covers it, what a month costs, and any rules.
Extras
Help Original Medicare doesn’t give you.
- Dental IncludedCleanings and exams covered. Some bigger dental work included, more with an optional add-on you can buy.
- Vision IncludedYearly eye exam: $0.
- Hearing Not includedYou can buy it as an add-on. See below.
- Over-the-counter items IncludedCovered for things like vitamins, pain relief and bandages.
- Fitness IncludedFitness benefit included.
- Rides to care Not included
- Extra help for some members IncludedIf you meet the plan’s health rules: “Advanced Care At Home”.The plan decides who qualifies.
- Other extras IncludedIncludes a nurse phone line or online visits, health classes, help with diet and nutrition and acupuncture.
Add-ons you can buy
Optional. Each costs extra every month, on top of the plan premium.
- NCAL Advantage Plus$20 a month · Adds dental, eye care and glasses, hearing and other extras
Help paying for this plan
Programs that can lower your Medicare costs if your income is limited.
Extra Help with drug costs
The drug part of this plan’s premium is already $0, so Extra Help would not lower the premium (the $95 medical part stays).
Extra Help also lowers what you pay for each medicine.
See who can get Extra HelpHelp with your Part B premium
A Medicare Savings Program can pay your Part B premium, and for some people more of their Medicare costs.
See who can get a Medicare Savings ProgramContact the plan
- Call about joining(800) 777-1238 · TTY 711
- Plan websitekp.org/medicare
- List of covered drugskp.org/seniorrx
- Find a pharmacykp.org/directory
- Full 2026 rulesRead the plan’s booklet (PDF)
From the details the plan filed with Medicare for 2026. To check whether a doctor takes this plan, call the doctor’s office, not the plan.