Health Education
No copayMandatory · referral required
IncludedKaiser Permanente Sr Adv Enhanced Santa Clara (HMO)
Kaiser Permanente
HMOSanta Clara CountyIncludes Part DPlan year 2026
$95/momonthly premium
$3,900most you pay in-network per year
4.5overall CMS star rating
42,856members enrolled, January 2026
Plan-level limits
Premium, deductibles, and the most you can pay out of pocket in a year.
In-network out-of-pocket maximum$3,900
Plan premium, per month$95
What a year on this plan would likely cost
What you pay for care
In-network costs for every service in this plan's CMS benefit filing. A copay is a fixed dollar amount; coinsurance is a percentage of the bill.
Hospital stays
Inpatient hospital stay
Days 1–5$260 per day
Days 6–90$0 per day
Inpatient psychiatric stay
Days 1–5$260 per day
Days 6–90$0 per day
Skilled nursing facility stay
Days 1–20$0 per day
Days 21–100$100 per day
Doctor visits
Primary care visit
$0
You pay nothing
Specialist visit
$15
Copay
Telehealth visit
$0
You pay nothing
Other health care professional
$0–$15
Copay, depends on the service
Chiropractic care (Medicare-covered)
$0
You pay nothing
Podiatry (Medicare-covered)
$15
Copay
Emergency and urgent care
Emergency room visit
$150
Copay
Urgent care visit
$0
You pay nothing
Emergency care outside the U.S.
$150
Copay
Urgent care outside the U.S.
$0
You pay nothing
Emergency transportation outside the U.S.
$300
Copay
Mental health and substance use
Individual therapy session
$0
You pay nothing
Group therapy session
$0
You pay nothing
Opioid treatment program
$0
You pay nothing
Partial hospitalization program
$0
You pay nothing
Referral required
Therapy and rehabilitation
Occupational therapy
$5–$10
Copay, depends on the service
Physical and speech therapy
$0–$10
Copay, depends on the service
Cardiac rehabilitation
$0–$15
Copay, depends on the service
Intensive cardiac rehabilitation
$0–$15
Copay, depends on the service
Pulmonary rehabilitation
$0
You pay nothing
Supervised exercise therapy for peripheral artery disease
$0
You pay nothing
Tests, labs and imaging
Lab services
$0
You pay nothing
Diagnostic tests
$0
You pay nothing
Diagnostic procedures
$0
You pay nothing
Diagnostic radiology (MRI, CT, PET)
$0–$275
Copay, depends on the service
Therapeutic radiology
$0
You pay nothing
Outpatient hospital and surgery
Outpatient hospital services
$0–$260
Copay, depends on the service
Ambulatory surgical center
$260
Copay
Observation services
$0–$150
Copay, depends on the service
Blood services
$0
You pay nothing
Home health care
Home health visit
$0
You pay nothing
Ambulance
Ground ambulance
$250
Copay
Air ambulance
$250
Copay
Medical equipment and supplies
Durable medical equipment
0–20%
Coinsurance, depends on the service
Medical supplies
0–20%
Coinsurance, depends on the service
Prosthetic devices
20%
Coinsurance — your share of the bill
Dialysis
Dialysis
20%
Coinsurance — your share of the bill
Part B drugs
Part B drugs
0–20%
Coinsurance, depends on the service
Chemotherapy drugs
0–20%
Coinsurance, depends on the service
Part B insulin
$7–$35
Copay, depends on the service
Preventive and wellness
Barium enema
$0
You pay nothing
Diabetes screening
$0
You pay nothing
Digital rectal exam
$0
You pay nothing
Electrocardiogram (EKG)
$0
You pay nothing
Glaucoma screening
$0
You pay nothing
Health education
$0
You pay nothing
Nursing hotline
$0
You pay nothing
Nutritional / dietary benefit
$0
You pay nothing
Web / phone access
$0
You pay nothing
Vision
Eye exam (Medicare-covered)
$0–$15
Copay, depends on the service
Routine eye exam
$0
You pay nothing
Hearing
Hearing exam (Medicare-covered)
$15
Copay
Extra benefits
Over-the-counter items
$0
You pay nothing
Acupuncture
$0
You pay nothing
Residential Substance Use Disorder and MH Treatment
$100
Copay
DME and Prosthetic/Medical Supplies not covered by Medicare
0–20%
Coinsurance, depends on the service
Extra benefits beyond Original Medicare
Supplemental benefits this plan filed with CMS, with the cap and period exactly as filed.
Nutritional/Dietary Benefit
No copayMandatory · referral required
IncludedRemote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Nursing Hotline; Web/Phone-based technologies
No copayMandatory · referral required
IncludedNot offered by this plan
In-Home Safety AssessmentPersonal Emergency Response System (PERS)Medical Nutrition Therapy (MNT)Post discharge In-Home Medication ReconciliationRe-admission PreventionWigs for Hair Loss Related to ChemotherapyWeight Management ProgramsAlternative TherapiesTherapeutic MassageAdult Day Health ServicesHome-Based Palliative CareIn-Home Support ServicesSupport for Caregivers of EnrolleesAdditional Sessions of Smoking and Tobacco Cessation CounselingFitness BenefitEnhanced Disease ManagementTelemonitoring ServicesHome and Bathroom Safety Devices and ModificationsCounseling Services
Dental
No dental deductible.
Preventive
Oral examsBoth, prior authorization
CleaningsBoth, prior authorization
X-raysBoth, prior authorization
Fluoride treatmentMandatory, prior authorization
Other diagnostic servicesBoth, prior authorization
Other preventive servicesBoth, prior authorization
Comprehensive
Restorative (fillings)Optional
Endodontics (root canals)Optional
Periodontics (gum treatment)No copay, prior authorization
Oral surgeryNo copay, prior authorization
Fixed prosthodontics (crowns, bridges)Optional
Removable prosthodontics (dentures)Optional
Adjunctive general servicesOptional
Prescription drugs (Part D)
$0 annual drug deductible · 6 formulary tiers · mail order available. Costs shown for a 30-day supply.
Initial coverage
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | — | No copay | — | — | Waived |
| 2. Generic | — | $7 copay | — | — | Waived |
| 3. Preferred Brand | — | $47 copay | — | — | Waived |
| 4. Non-Preferred Drug | — | $100 copay | — | — | Waived |
| 5. Specialty Tier specialty | — | 33% coinsurance | — | — | Waived |
| 6. Vaccines | — | No copay | — | — | Waived |
Catastrophic (after the out-of-pocket threshold)
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | No copay | No copay | No copay | — | Waived |
| 2. Generic | No copay | No copay | No copay | — | Waived |
| 3. Preferred Brand | No copay | No copay | No copay | — | Waived |
| 4. Non-Preferred Drug | No copay | No copay | No copay | — | Waived |
| 5. Specialty Tier specialty | No copay | No copay | No copay | — | Waived |
| 6. Vaccines | No copay | No copay | No copay | — | Waived |
Out-of-pocket threshold for the catastrophic phase: $2,100.
Is my medicine on this plan’s list?
Pharmacies near you in this plan's network
From the plan's filed Part D pharmacy network, matched to geocoded pharmacy locations. Preferred pharmacies come first: they carry the lower copay column in the tier table above. The ZIP you enter stays in this browser.
CMS star ratings
Star ratings are set by CMS for the whole contract, so every plan under this contract shares them.
4.5 out of 5Overall rating
4 out of 5Health services (Part C)
5 out of 5Drug plan (Part D)
Staying healthy: screenings, tests and vaccines
4- Annual flu vaccine5
- Breast cancer screening5
- Colorectal cancer screening5
- Monitoring physical activity5
- Improving or maintaining mental health1
- Improving or maintaining physical health2
Managing chronic (long-term) conditions
4- Readmissions3
- Kidney health5
- Blood pressure5
- Reducing falls2
- Statin therapy5
- Bladder control2
- Diabetes eye exam5
- Transitions of care5
- Diabetes blood sugar4
- Osteoporosis management5
- Followup after emergency department visit4
- Medication reconciliation5
Member experience with the health plan
3- Customer service3
- Care coordination2
- Healthcare quality4
- Health plan rating5
- Getting needed care3
- Getting appointments2
Member complaints and changes in the plan's performance
5- Complaints5
- Members leaving5
- Quality improvement4
Health plan customer service
4- Call center4
- Timely decisions4
- Appeals decisions4
Drug plan customer service
4- Call center foreign language interpreter and TTY availability4
Drug plan complaints and changes
5- Complaints5
- Members leaving5
- Quality improvement5
Member experience with the drug plan
5- Drug plan rating5
- Prescription drugs5
Drug safety and accuracy of drug pricing
4- Price accuracy5
- Statin diabetes4
- Medication therapy management comprehensive medication review completion4
- Medication adherence for diabetes medications4
- Medication adherence for hypertension RAS antagonists s4
- Medication adherence for cholesterol statins4
Why members leave this contract
Service area and network
Sold in 1 California county.
Santa Clara
Doctor directory
1,413 providers are named in Kaiser Permanente’s directory for this plan, dated Sep 1, 2026.
A doctor named there is listed. A doctor missing from it is unknown, never out of network: carrier directories are partial and change monthly. Open the carrier directory
Contract with Medicare sinceAug 1, 1987
Medicare Advantage regionCalifornia
Ask about this plan
A question box grounded in this plan's filed benefits, drug list, and pharmacy network. It reads the same records shown on this page and says so when something is not filed.
Answers come from this plan’s filed benefits, drug list, and pharmacy network. They are not enrollment advice; the Evidence of Coverage is the final word.