Medicare Plan Summary of Benefits Chart
This chart provides a summary of benefits only. In any instance where information in this chart or Guide conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail. For a detailed description of benefits and exclusions, please review your plan’s EOC.
This chart provides a summary of benefits only. In any instance where information in this chart or Guide conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail. For a detailed description of benefits and exclusions, please review your plan’s EOC. EOCs are available for download at sfhss.org.
medicare plans | ||
|---|---|---|
KAISER PERMANENTE | BLUE SHIELD MEDICARE | |
Choice of Physician | PCP assignment required. | You may use any Medicare provider regardless of whether they are in-network or out-of-network. |
| Deductible | No Deductible | No Deductible |
| Annual Out-of-Pocket Maximum | $1,000/individual | $3,750/individual |
| General Care and Urgent Care | ||
| Routine Physical | $0 co-pay | $0 co-pay |
| Doctor Office Visit | $20 co-pay | $5 co-pay PCP; $15 co-pay Specialist |
| Urgent Care Visit | $20 co-pay | $20 co-pay waived if admitted to the hospital within 24 hours |
| Well Woman Exam & Family Planning | $0 co-pay | $0 co-pay |
| Immunizations | $0 co-pay | $0 co-pay |
| Lab and X-ray | $0 co-pay | $0 co-pay |
| Doctor's Hospital Visit | No charge | No charge |
| Prescription Drugs | ||
| Pharmacy: Generic | $5 co-pay 30-day supply | $5 co-pay 30-day supply |
Pharmacy: Brand-Name | $15 co-pay 30-day supply | $20 co-pay 30-day supply |
Pharmacy: Non-Formulary | Only if authorized by a Kaiser Physician | $45 co-pay 30-day supply |
| Mail Order: Generic | $10 co-pay 100-day supply | $10 co-pay 100-day supply |
Mail Order: Brand-Name | $30 co-pay 100-day supply | $40 co-pay 100-day supply |
Mail Order: Non-Formulary | Only if authorized by a Kaiser Physician | $90 co-pay 100-day supply |
| Specialty | 20% coinsurance up to $100 per prescription; 30-day supply | $20 co-pay retails pharmacy up to 30-day supply; $40 co-pay mail/home delivery pharmacy up to 90-day supply |
| Hospital Outpatient and Inpatient | ||
| Hospital Outpatient | $35 co-pay | $100 co-pay |
| Hospital Inpatient | $100 co-pay per admission | $150 co-pay per admission |
| Hospital Emergency Room | $50 co-pay waived if hospitalized | $65 co-pay waived if admitted to the hospital within 24 hours |
| Skilled Nursing Facility | $0 co-pay 100 days per benefit period | $0 co-pay 100 days per benefit period |
| Hospice | No charge when medically necessary | Covered by Original Medicare |
| Post-Discharge Support and Routine Transportation | ||
| Post Discharge Meal Delivery | $0 co-pay up to three meals per day in a consecutive four-week period, once per calendar year | $0 co-pay for 30 meals, 16 snacks; per discharge |
| Routine Transportation | $0 co-pay for up to 24 one-way trips (up to 50 miles per trip) per calendar year to facilitate non-emergent access to healthcare | $0 co-pay for 24 one-way trips (up to 70 miles per trip) per calendar year to facilitate non-emergent access to healthcare |
| Mental Health and Substance Abuse Services | ||
| Outpatient Treatment | $10 co-pay group $20 co-pay individual | $5 co-pay group $15 co-pay individual |
| Inpatient Facility | $100 co-pay per admission | $150 co-pay per admission |
| Inpatient Detox | $100 co-pay per admission | $150 co-pay per admission |
| Residential Rehabilitation | $100 co-pay per admission, physician approval required | $150 co-pay per admission |
| Other | ||
| Hearing Aids | Evaluation no charge, 1 aid per ear, every 36 months, up to $2,500 per ear. | Evaluation no charge, 1 aid per ear, every 36 months, up to $2,500 per ear. |
| Medical Equipment, Prosthetics and Orthotics | $0 co-pay when medically necessary | $15 co-pay |
| Physical and Occupational Therapy | $20 co-pay; authorization required | $20 co-pay |
| Acupuncture/ Chiropractic | $15 co-pay up to a combined total of 30 chiropractic and acupuncture visits/ year; ASH network | $15 co-pay 24 visits of Acupuncture max per plan year, ASH network in CA $15 co-pay 24 visits of Chiropractor max per plan year, ASH network in CA |
| Gender Dysphoria | Co-pays apply; authorization required | Co-pays apply; authorization required |