NOTE: If you are eligible for coverage in this calendar year and wish to be enrolled before January 1, 2021, see our plans for 2020.
This plan received Medicare's highest possible rating (5 out of 5 stars) for 2021*
Kaiser Permanente Senior Advantage (HMO) Individual plans
Areas covered by this plan are noted beneath the tables.
2021 benefits highlights
Effective January 1, 2021, to December 31, 2021
Premiums and Benefits
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
Doctor Office Visits
$5 Primary / $10 Specialist
Email, phone and video visits with a Permanente Medical Group provider
$100 per day for days 1 through 7 No charge for the remainder of your stay
Skilled Nursing Facility
Up to 100 days per benefit period
$0 per day for days 1 through 20
$75 per day for days 21 through 100
$0 Lab, $15 X-Ray
MRI, CT and PET
Durable Medical Equipment
Per one-way trip
Annual Maximum Out-of-Pocket
For more information about benefits, please view the 2021 Summary of Benefits.
These plans include Medicare Part D prescription drug coverage. Copay and coinsurance amounts below are for up to a month’s supply. You can save on most refills of a 3-month supply through our mail order pharmacy and have them mailed to your home at no extra charge.2
Premiums and Benefits
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
Part D Prescription Drug Coverage
Initial Coverage Stage
For up to a 30-day supply. When the annual total drug costs paid by you and any Part D plan reach $4,130, you move into the Coverage Gap Stage.
$3 Preferred Generic (Tier 1)
$10 Generic (Tier 2)
$47 Preferred Brand-name (Tier 3)
$100 Nonpreferred Brand-name (Tier 4)
33% Specialty (Tier 5)
$0 Injectable Part D Vaccines (Tier 6)
Coverage Gap Stage
For up to a 30-day supply. If your annual out-of-pocket costs reach $6,550, you move into the Catastrophic Coverage Stage.
$3 Preferred Generic (Tier 1)
$10 Generic (Tier 2)
25% Preferred Brand-name (Tier 3)
25% Nonpreferred Brand-name (Tier 4)
25% Specialty (Tier 5)
$0 Injectable Part D Vaccines (Tier 6)
Catastrophic Coverage Stage
When your annual out-of-pocket costs exceed $6,550, you pay these amounts for the remainder of the calendar year.
$3 Preferred Generic (Tier 1)
$3 Generic (Tier 2)
$12 Preferred Brand-name (Tier 3)
$12 Nonpreferred Brand-name (Tier 4)
$12 Specialty (Tier 5)
$0 Injectable Part D Vaccines (Tier 6)
Our Mail-Order Pharmacy2
Save time and money with prescriptions mailed right to your home.
$0 copay for up to a 100-day supply of preferred generic drugs. All other drugs: 2 copays for up to a 100-day supply. Restrictions and limitations may apply.
1$0 copay for all preventive services covered under Original Medicare at zero cost sharing. 2For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-order pharmacy. You should receive them within 3-5 days. If not, please call 866-206-2983 (TTY 711).
To find out how much you'll pay for your prescription drugs, you can use Kaiser Permanente's drug pricing tool to search for drug information, pharmacy pricing, and lower cost options.
Note: If you have health care coverage through an employer or trust fund, please contact your benefits administrator for information about your group plan.
*Every year, Medicare evaluates plans based on a 5-star rating system. In 2021, Kaiser Permanente California, Colorado, Georgia, Hawaii, Mid-Atlantic, and Northwest regions received 5 out of 5 stars. Washington region received 4.5 out of 5 stars.
Kaiser Permanente Senior Advantage Medicare Medi-Cal (HMO D-SNP) plan
If you are eligible for both Medicare and full benefits under Medi-Cal, you may qualify for the Kaiser Permanente Senior Advantage Medicare Medi-Cal (HMO D-SNP) plan.
With this plan you'll have:
No monthly premiums
No copays for medical services, including doctor office visits with primary care physicians and specialists
Medicare Part D drug coverage for generic and brand-name drugs ― with very low copays
Note: Our Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan is available to individual plan members only. If you're a member of a Kaiser Permanente plan through your employer or labor and trust organization, call us to find out how to qualify.
Kaiser Permanente is an HMO D-SNP plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in Kaiser Permanente depends on contract renewal.
Our Medicare Part D drug formulary is a list of the prescription drugs that are approved for coverage by Kaiser Permanente's Medicare health plan. Learn more about our Part D drug formulary below.
Move a drug to a lower or higher cost-sharing tier (Note: This may not apply to all plans.)
Usually these types of changes won’t affect you until January 1 of the next year. But in some cases, you’ll be affected by a change before January 1. If that happens, we’ll either tell you 30 days before the change, or give you a 30-day supply when you ask for a refill at a Kaiser Permanente or affiliated pharmacy.
If the FDA decides a drug on our formulary isn’t safe, or if the drug’s manufacturer removes the drug from the market, we’ll immediately remove the drug from our formulary and notify members who take the drug.
For current information about drugs covered by Kaiser Permanente, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Spanish: 1-800-788-0616 (TTY 711) Chinese dialects: 1-800-757-7585 (TTY 711)
The formularies on this page are updated regularly and will reflect any changes that happen during the year.
We’ll also let you know about these changes in your Explanation of Benefits or Provision of Notice (Coming Soon).
What if the drug I want isn’t on the formulary or has restrictions?
If your drug isn’t on the formulary or there are restrictions, you can:
Ask your Kaiser Permanente or affiliated doctor to prescribe a similar drug on our formulary
Ask us to waive restrictions, such as prior authorization
Ask us to make an exception and cover your drug
Ask us to cover certain Part D formulary drugs at a lower cost-sharing level — as long as they aren’t in the specialty tier (Tier 5) (Note: This may not apply to all plans.)
In certain situations, you may be able to get a temporary supply of the drug. This will give you and your doctor time to change to another drug, or file for an exception. Please refer to your Evidence of Coverage for details.
How do I request an exception to the formulary?
If you or your doctor asks for an exception, you may give us a doctor’s statement supporting your request. Generally, we must make our decision within 72 hours of getting your request for a coverage decision if we have your doctor’s statement.
If waiting up to 72 hours could be harmful to your health, either you, your Kaiser Permanente doctor, or affiliated doctor can ask for an expedited (fast) exception. If the fast request is approved, we’ll make a decision within 24 hours of getting your doctor’s supporting statement.
If you can’t get a supporting statement from your doctor, you may ask for a coverage determination, which is a decision we make about whether we’ll cover a Medicare Part D drug and the amount you’ll need to pay.
Please keep in mind:
Exceptions are only approved when alternative drugs on our formulary, lower-tiered drugs, or adding usage restrictions wouldn’t be effective or would be harmful.
You can only request an exception for drugs considered to be Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS).
You can’t get an exception for drugs that are excluded under Medicare Part D.
Please see your Evidence of Coverage for more information about exceptions or coverage determinations, including the appeals process. You can also go to our website’s FAQ section, which includes information on grievances, coverage determinations, and appeals.
What if I have a hospital stay or live in a long-term care or skilled nursing facility?
If you’re admitted to a hospital or a skilled nursing facility for a stay covered by our plan, we’ll generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, we’ll cover your drugs if they meet all our rules for coverage.
If you live in a long-term care facility, such as a nursing home, you may get your prescription drugs from the facility’s pharmacy if it’s an affiliated pharmacy.
To find out if a pharmacy is affiliated with Kaiser Permanente, check the pharmacy directory located under the Kaiser Permanente and affiliated pharmacies section. You can also call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Please see your Evidence of Coverage for details about your coverage, our transition policy♦, and drugs not covered by Medicare Part D.
You must show your Kaiser Permanente Senior Advantage (HMO) ID card and photo ID at a Kaiser Permanente or affiliated pharmacy. You’ll need to pay your share of the cost when you pick up your prescription.
If you don’t have your ID card with you, or if you go to a non-affiliated pharmacy (out-of-network), you may have to pay full price for your medicines.
If this happens, ask us to pay you back for our share of the cost by submitting a claim form. Learn how to submit a claim in your Evidence of Coverage.
What if I use a pharmacy that isn’t a Kaiser Permanente or affiliated pharmacy?
This would be considered a non-affiliated or out-of-network pharmacy. Prescriptions filled at an out-of-network pharmacy will only be covered when a Kaiser Permanente or affiliated pharmacy isn’t available or certain situations.
Here are the situations when prescriptions at an out-of-network pharmacy would be covered:
You need the drug right away and there’s no 24-hour Kaiser Permanente or affiliated pharmacy within a reasonable driving distance.
You’re traveling within or outside the United States and need out-of-network emergency or urgent care.
Your drug isn’t regularly stocked at an accessible Kaiser Permanente or affiliated pharmacy or isn’t available through our mail-order service.
You can’t get drugs from a Kaiser Permanente or affiliated pharmacy during a disaster.
In these situations, you’ll have to pay the full cost when you fill the prescription. You’d then file a claim asking us to pay you back for our share.
To learn more about out-of-network pharmacy coverage and find out how to file a paper claim, see your Evidence of Coverage.
Save time by ordering your prescription refills through one of the following ways:
Order online under the Pharmacy section at kp.org. You'll need to sign on to your registered account. If you don't have an account yet, register for a secure account to use the service.
Order through the Kaiser Permanente mobile app. Download the app by searching for Kaiser Permanente on the Apple Store or the Google App Store.
Call the phone number on the label of your medicine.
Call our mail-order service at 1-866-206-2983 (TTY 711), 7 a.m. to 7 p.m., Monday through Friday.
When you order refills by mail, there’s no charge for shipping and your costs could be lower when you order a 3-month supply. Ask your Kaiser Permanente pharmacy, affiliated pharmacy, or our mail-order pharmacy if your prescription is available by mail.
Contact us at least 5 days before you run out of your medicines to make sure your next mail-order refill is shipped to you in time. Generally, you should receive them within 3-5 days.
If you can’t wait for your prescription to arrive from our mail-order pharmacy, you can get an urgent supply by calling your local Kaiser Permanente or affiliated pharmacy listed in your pharmacy directory located under the Kaiser Permanente and affiliated pharmacies section.
Find more information about our mail-order service* in your Evidence of Coverage.
*For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-order pharmacy. Usually, you should receive them within 5 days. If not, please call 1-866-206-2983 (TTY 711).
Kaiser Permanente provides a Medication Therapy Management (MTM) program for eligible members who have several chronic medical conditions, take different prescription drugs at the same time, and have high drug costs.
The program connects you to specially trained pharmacists who make sure all the medicines you take are necessary, safe, and effective.
The MTM program isn’t a benefit. It’s a voluntary, extra service offered at no cost to members who qualify.
Am I eligible for the MTM Program?
To be eligible, you must be a current Kaiser Permanente member with a Medicare health plan that includes Medicare Part D coverage.
You must also be able to say yes to the following 3 factors.
1.You have 3 or more of these health conditions:
High blood pressure
Coronary artery disease
Chronic obstructive pulmonary disease
Chronic non-cancer pain
Benign prostatic hyperplasia (BPH)
2. You take 5 or more of these prescription drugs:
Drugs for high cholesterol
Drugs for high blood pressure
Drugs for diabetes
Drugs for rheumatoid arthritis
Drugs for gout
Urinary Incontinence Agents
3.You spend more than $4,376 each year on prescription drugs.
How do I enroll in the MTM program?
If you qualify, you’ll be automatically enrolled in the MTM program. A member of the MTM team will either call you or send you a letter asking you to set up an appointment for a comprehensive review of all your medicines.
To prepare for this review, please fill out this personal medication form♦ and include all the medicines you’re currently taking.
Most reviews are done by phone and take 15 to 20 minutes. In some cases, you may also need to do a targeted medication review that lasts 10 to 15 minutes.
We’ll talk about your prescription medicines and any over-the-counter, herbal, or dietary supplements you take. We’ll look for ways to reduce side effects, prevent harmful drug interactions, and lower drug costs.
You’ll receive a written summary of the review that includes an action plan based on your needs to help you get the most out of your medicines.
For more information, see this MTM flyer.♦ You may also call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
If you’re a Kaiser Permanente Senior Advantage (HMO) member with limited income and resources, you may qualify for Extra Help, a Medicare program that helps you pay for prescription drugs.
If you’re eligible, Medicare could pay for some or most of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Plus, some people may not have to pay the coverage gap cost share or a late enrollment penalty.
How do I know if I qualify?
Some people who qualify for Extra Help are automatically enrolled and don’t need to apply. Medicare will mail them a letter to let them know.
To find out if you qualify, you can do one of the following:
Call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Call Medicare at 1-800-MEDICARE (1-800-633-4227) or (TTY 1-877-486-2048), 24 hours a day, 7 days a week. Or visit Medicare website.†
Call Social Security at 1-800-772-1213 or TTY 1-800-325-0778, 7 a.m. to 7 p.m., Monday through Friday.
Contact your state Medicaid office (Medi-Cal in California).
2021 Extra Help premium summary chart
Here’s what your monthly plan premium will be if you get Extra Help. The premiums listed are for both medical services and prescription drug benefits. This does not include a Medicare Part B premium.
Your level of Extra Help
Los Angeles and Orange Counties Plan
Medicare Medi-Cal Plan for Southern California*
*In the Los Angeles, Orange, San Diego, Riverside, and San Bernardino counties, you must be a current Kaiser Permanente member to enroll in Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan.
I already get Extra Help. Will my costs change next year?
Here’s how your costs will change if you qualify for the same level of help next year.
If you pay this much in 2020
You will pay this much in 2021
$1.30 for generics and brands that are treated as generics $3.90 for brand-name drugs
$1.30 for generics and brands that are treated as generics $4.00 for brand-name drugs
$3.60 for generics and brands that are treated as generics $8.95 for brand-name drugs
$3.70 for generics and brands that are treated as generics $9.20 for brand-name drugs
No more than 15% coinsurance for all drugs
No more than 15% coinsurance for all drugs
Note: If the amount listed in your Evidence of Coverage Rider for People Who Get Extra Help Paying for Their Prescription Drugs is less than the amount listed above, you’ll pay the lower amount. Please refer to this document for more details.
What if I qualify for Extra Help and believe I’m not being charged correctly?
If you’re eligible for Extra Help, or you believe you’re eligible, and you think you aren’t paying the correct premium or drug costs, you may be able to correct your records by giving us information known as Best Available Evidence (BAE).
Examples of BAE include:
Your Extra Help Social Security award letter
Your state Medicaid card
For more information on what qualifies as BAE, or to learn how to submit it to us, please refer to your Evidence of Coverage. You can also call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Kaiser Permanente has quality assurance measures that are meant to prevent medication errors, harmful drug interactions, and to improve medication use.
Our pharmacy policies and procedures meet state and federal laws and include:
Drug utilization reviews that are performed before each new prescription is given to check for issues like interactions with other drugs or allergies
Computerized systems that check records to spot drug therapy problems
Systems to spot and reduce medication errors
If you have a complaint about your Kaiser Permanente care:
You can file a grievance with Kaiser Permanente. For more information on how to file please see your Evidence of Coverage. Or call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
You can file a complaint with the Quality Improvement Organization (QIO). The QIO review of a quality-of-care issue is separate from Kaiser Permanente’s Medicare Part D grievance procedures, so you can file with both.
You can file a complaint with the local QIO by writing to:
Livanta BFCC – QIO Program 9090 Junction Drive, Suite 10 Annapolis Junction, MD 20701
Or call the QIO at 1-877-588-1123 (TTY 711).
Drug Utilization Management
Kaiser Permanente has requirements, restrictions, or limits on some covered prescription drugs. These are established by a team of doctors and pharmacists to prevent waste, manage member costs, ensure safe and effective drug use, and to comply with FDA and Medicare guidelines. For example, there are limits on opioid prescriptions, such as lower doses and shorter courses, to ensure your prescribed drug is safe, appropriate and medically necessary.
You may need to get preapproval (prior authorization) from us before you fill certain prescriptions. If you don’t get preapproval, we may not cover the drug.
Drugs needing our approval♦ could be covered under Medicare Part B or Part D, depending on your medical diagnosis. More details from your prescriber might be required to make that decision.
You may need to get an approval for certain Part D drugs if you’re admitted to hospice. Hospice providers can complete this form♦ if necessary.
For more information, please see the Kaiser Permanente comprehensive formulary.
Let us know right away if you have questions, concerns, or problems related to your covered services or care by calling Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
A representative will help determine whether your concern should be handled as a grievance, coverage determination, or an appeal. Here’s the difference:
A grievance is a type of complaint you make about us, including a complaint about the quality of your care. It doesn’t involve coverage or payment disagreements.
A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay for it, or reimbursement if you feel you’ve paid too much.
An appeal can be made if you disagree with our decision to deny a request about your Part D drugs.
A Member Services representative can help you file a grievance, coverage determination, and/or appeal. You can also refer to your Evidence of Coverage for more information about the process.
How do I ask for a coverage determination?
You, your appointed representative, your Kaiser Permanente or affiliated doctor, or another prescriber can request a coverage determination.
The CMS coverage determination form♦ makes it easy to provide evidence supporting your request. You don’t have to use the form, but your request must include all the information from the form.
If you appoint a representative to act on your behalf, you both must sign and date a Disclosure Authorization form along with your Medicare Authorized Representative statement, which gives that person legal permission to act as your appointed representative.♦
Effective January 1, 2021, you can ask for a coverage determination in the following ways:
Call the OptumRx Member Services Prior Authorization Dept. at 1-888-791-7213 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Fax the completed form or information to OptumRx Member Services Prior Authorization Dept. at 1-844-403-1028.
Mail the completed form or information to:
OptumRx c/o Prior Authorization P.O. Box 25183 Santa Ana, CA 92799
How long will it take for a decision?
A standard decision will be made within 72 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement.
An expedited (fast) decision will be made within 24 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement.
What if my request for an expedited decision isn’t approved?
An expedited (fast) decision will only be allowed if your doctor confirms that waiting 72 hours could seriously harm your health.
If your request for an expedited decision isn’t approved, we’ll make our decision in the standard 72-hour time frame.
If we deny your expedited review by phone and you disagree with our decision, you can ask for a 24-hour expedited grievance at that time. Otherwise, we’ll send a letter within 3 calendar days explaining how to file the expedited grievance. It’ll also explain that we’ll automatically give you an expedited decision if you get the prescribing Kaiser Permanente or affiliated doctor’s support for an expedited review.
If you believe you were incorrectly charged through our coverage determination process, you may submit a reimbursement request. Once we receive it, we’ll respond within 14 calendar days. If approved, payment will be made within 14 calendar days.
To ask questions or to check on the status of a request, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
How do I file an appeal to a coverage determination?
If you disagree with our coverage determination, you have the right to file an appeal called a plan redetermination. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for the delay.
You can file your request for a plan redetermination in writing by mailing it to the address on your denial notice. An expedited request may also be filed in writing, or by contacting us by telephone or fax at the numbers provided in your coverage determination denial letter.
Kaiser Permanente Attention: Medicare Part D Review P.O. Box 23170 Oakland, CA 94623-0170
You also have the right to give us new information supporting your appeal in writing, by telephone, by fax, or by hand-delivering it to your local Member Services department.
How long does a decision on an appeal take?
A standard appeal decision will be made within 7 calendar days. For pre-service exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review. If our decision is fully in your favor, we must authorize the service within 7 days and/or make the payment within 14 calendar days.
If waiting for a standard decision could seriously harm your health or compromise your ability to regain maximum function, you or your prescribing Kaiser Permanente or affiliated doctor may request an expedited appeal for a decision within 72 hours. For exception requests, the timeframe begins when your doctor or other prescriber provides a supporting statement, if not provided during the initial review. This process doesn’t apply to denied claims for payment.
Who do I contact if I have questions?
If you have questions or concerns about services or your care, problems with a particular Medicare Part D drug, or need help getting a representative to handle your coverage determination or appeal, you may submit a complaint online or call Member Services at 1-800-443-0815 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
For additional assistance, you can also visit the Member Services department at your local Kaiser Permanente facility.
How do I find out about grievances, appeals, and exceptions filed by other plan members?
You can get a summary of the appeals and grievances other plan members have filed with Kaiser Permanente by calling Member Services.
How do I report suspected fraud or other unlawful acts?
We encourage anyone to let us know if anything happens at Kaiser Permanente that could be unlawful. If we know about it, we can take action.
If you believe you’ve experienced fraud, or you become aware of fraud, waste, or abuse involving Kaiser Permanente members or resources, please contact Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
You can also contact Medicare for fraud-related questions and concerns at:
If you leave Kaiser Permanente Senior Advantage (HMO), you have other prescription drug coverage options:
Medicare Prescription Drug Plan (PDP) This plan adds prescription drug benefits to your Original Medicare coverage. To enroll, you must be entitled to Medicare benefits under Part A and/or currently enrolled in Part B and live in the plan’s service area.
Medicare Advantage Prescription Drug Plan (MA-PD) You can join another Medicare Advantage Plan if it’s available in your area, is accepting new members, and you meet the plan’s eligibility requirements.
If you choose to join another Medicare Advantage plan that offers prescription drug coverage, then you must get your Medicare prescription drug coverage through that Medicare Advantage plan.
For more information about disenrolling from our plan, please review chapter 10 in your Evidence of Coverage.
For general information about Kaiser Permanente: Please call Member Services at 1-800-443-0815 or (TTY 711), 8 a.m. to 8 p.m., 7 days a week. For information in Spanish, call 1-800-788-0616 (TTY 711), 8 a.m. to 8 p.m., 7 days a week.
Or you can mail a letter to:
Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. Pasadena, CA 91188-8514
If you have questions about your medicines: Please talk to your Kaiser Permanente or affiliated doctor, or to someone in your Kaiser Permanente or affiliated pharmacy.
For more information about Medicare prescription drug coverage: Call 1-800-MEDICARE (1-800-633-4227) or (TTY 1-877-486-2048), 24 hours a day, 7 days a week. Or visit the Medicare website.†
Click on the links below for detailed information about Kaiser Permanente’s Medicare health plans.