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KaiserPermanenteMedicareAdvantage(HMO)See how we can help you thrive2022 Plans and BenefitsPuget Sound regionKing, Kitsap, Lewis, Pierce, Snohomish, Thurston,and parts of Mason and Grays Harbor countiessH5050 MA0002036 53 21 M
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Why choose Kaiser Permanente?Whether you’re turning 65, ready to retire, or recently moved into theKaiser Permanente Washington service area, you’ll want to consider ourMedicare Advantage (HMO) health plans. They combine high-quality careand coverage in one convenient package because we’re both a medicalgroup and a health plan.In this booklet, you’ll see how our Medicare Advantage health plans canhelp you live life to the fullest — and you’ll understand why we’re the plan ofchoice for almost 100,000 Medicare Advantage members in Washington.1And if you have any questions about our plans, feel free to call us from8 a.m. to 8 p.m., 7 days a week:Prospective members1-800-446-8882 (TTY 711)Current members1-888-901-4600 (TTY 711)We’ll help you get started with yourcare and coverage2s2022 Plans and BenefitssWhen you become a Kaiser Permanentemember, our New Member WelcomeTeam will help you find a doctor, locate aKaiser Permanente medical facility nearyou, transfer prescriptions, and transitionany ongoing treatment from non-KaiserPermanente providers to Kaiser Permanente.
High-quality care focused on youHighly-ranked doctorsConnected care for better careWashington Permanente Medical Group isone of the highest-ranked medical groups inthe state.2 Our doctors, specialists, and careteams are here to provide you with care tohelp you be your healthiest.Your doctors, specialists, and care teams are allconnected to you and to each other throughyour electronic health record. They use yourhealth history to work together, inform theircare, and support your total health.Specialists and specialty careCare under one roofWhen you need care for a specific healthmatter, you can count on Kaiser Permanentespecialists. Our doctors include some of thenation’s leading specialists in more than 60medical, surgical, and therapeutic specialties.At most Kaiser Permanente locations, youcan take care of what you need in one visit:see your doctor, get a lab test or X-ray, andpick up your medications — all without leavingthe building.Mental health and wellnessCare in Washington service areaIf you’re struggling with depression, anxiety,or other mental or emotional issues thatinterfere with your daily life, we make it easyfor you to get help. We offer a broad range ofmental health care options and support thatyou can access at any time.With the Kaiser Permanente MedicareAdvantage HMO Individual network, youget access to care from all available KaiserPermanente doctors, specialists, and careteams, as well as all available affiliatedcommunity providers across our service area.WhatcomWashington service areaSkagitIslandThe service areaincludes certain GraysHarbor County andMason County ZIP codes:SnohomishKitsapMasonMason County:98524, 98528, 98546, 98548,98555, 98584, 98588, 22 Plans and BenefitssGrays Harbor County:98541, 98557, 98559, 98568
Care near youArizona snowbirds take noteTo find in-network doctors andfacilities in your area, visitkp.org/wa/find-a-doctor.Our plans include in-network coveragefor care from select Banner Healthproviders in Arizona’s Pima andMaricopa counties.3To find Kaiser Permanente locations,visit kp.org/wa/locations.Care outside of Washingtonservice areaYou’re covered for urgent and emergencyservices anywhere in the world. And you’llbe reimbursed for emergency prescriptionsfilled at out-of-network pharmacies in theUnited States and its territories.You’re also covered for care at any KaiserPermanente medical facility in California,Colorado, Georgia, Hawaii, Maryland,Oregon, Virginia, and Washington, D.C.3Care in states without KaiserPermanente facilitiesWherever you are, we’re ready tohelp you For advice or help deciding where togo for care — call our 24/7 ConsultingNurse Service. For coverage information or helpfinding an in-network provider — callMember Services. If you get your care from a KaiserPermanente doctor or care team — emailthem nonurgent health questions.4s2022 Plans and BenefitssYou can get in-person care at any CVSMinuteClinic or Concentra urgentcare center.4
Connect to care any way you wantIn addition to in-person care, we make it easy for you to connect virtually with yourKaiser Permanente doctors and care teams — all at no additional cost to you.5Care ChatEmailGet real-time medical care onlinefrom a clinician.Message your Kaiser Permanentecare team with nonurgentquestions and get a reply, usuallywithin 2 business days.Meet face-to-face with a KaiserPermanente clinician by video.E-visitGet an online diagnosis forcommon medical issues that don’tneed a physical exam.Phone appointmentMake a phone appointment to talkwith your doctor over the phone.24/7 phone adviceCall our Consulting Nurse Servicefor advice, day or night.5s2022 Plans and BenefitssVideo visit
Manage your care onlineYou can use our secure member website and the Kaiser PermanenteWashington mobile app to stay on top of your care anytime, anywhere.Find a doctorSee billingstatementsOrderprescriptionsPay billsTake a healthassessmentReview yourcoverage documentsAccess onlinecare optionsCheck yourdeductible statusFEB12 Email your health care team with nonurgent questions See preventive care reminders Make appointments Review scheduled appointments View lab and test results Review your after-visit summaries6s2022 Plans and BenefitssAnd if you get your care from Kaiser Permanente doctorsand care teams, you can also:
Benefits to help you thrive Annual physical examcovered in fullRoutine acupuncture andchiropractic care included onselect plansVision benefits Routine eye exam coverage Eyewear allowance to usetoward your purchase of glassesand contact lensesDental benefits Routine hearing exam coverage Hearing aid allowance touse toward your purchase ofhearing aids included onselect plansAnnual wellness visitcovered in fullAlternative care benefits Hearing benefitsPreventive and diagnosticdental benefits through DeltaDental of Washington includedon select plansOptional dental plan throughDelta Dental of Washingtonfor comprehensive dentalcoverage7 Dental reimbursementallowance to use toward yourpurchase of dental servicesfrom a licensed dentist includedon select plansuSee page 10 for moreinformation.Routine transportationbenefitRides to and from your medical anddental appointments, as well as anyin-network pharmacy8Care while traveling benefits Coverage for emergencyand urgent care anywhere inthe world Access to care at any KaiserPermanente facility in theUnited States3 Coverage for routine care atselect providers in Arizona’sPima and Maricopa counties3Over-the-counter (OTC)wellness benefit9Included on select plans, non prescription products — suchas vitamins, allergy and coldremedies, pain relievers, stomachaids, and more — are availablefor you to order based on yourplan’s quarterly benefit limit anddelivered to your doorstep at nocost to you7s2022 Plans and BenefitssPreventive care benefits6
Silver&Fit Healthy Aging and Exercise Program10A robust benefit that offers many fitness options to helpkeep you fit and healthy. The program includes: An annual fitness center membership — with alarge network of centers available to choose from Signature Series workout classes — available atparticipating locations A Home Fitness kit — kits include the Fitbit orGarmin Wearable Fitness Tracker Kit, as wellas various strength kits, yoga kits, and more The Get Started program — a personalizedexercise plan based on your answers to anonline questionnaire On-demand workout videos — with more than8,000 videos available for you to choose fromPlus many other classes and resources to help youexercise regularly.Resources for your body, mind, and spiritmyStrength , an emotionalwellness program to improveawareness and change behaviors11Calm, an app to help lower stress,reduce anxiety, improve sleep,and moreOne-on-one wellness coachingby phone for support in losingweight, becoming more active,eating healthier, and moreClasses, workshops, supportgroups, and resources topromote healthy living andwellness. Check out our offeringsat kp.org/wa/classesResource Line to find supportservices at Kaiser Permanenteand in the community forseniors and caregivers. See theresources available atkp.org/wa/resource-line8s2022 Plans and BenefitssTobacco cessation support to helpstop tobacco use for good
Prescription drug coverageOur plans with Part D cover a list ofMedicare-approved drugs ranging frompreferred generic drugs to brand-namedrugs to specialty medications andinjectable Part D vaccines. To see if yourprescription drugs are covered, searchour Medicare drug formulary atkp.org/wa/medicare/formulary.Our plans with Part D also feature: Low copays on certain generic drugs Broader drug coverage to help youthrough the coverage gap or “donut hole”phase. (For details about the coveragegap, visit medicare.gov.)uSee page 14 for details.Ordering prescriptions made easyOnce your prescriptions are in the KaiserPermanente pharmacy system, you can signin to our secure member website or mobileapp to see your prescriptions and requestrefills. You also can choose whether you wantto receive your refills by mail or have themwaiting for you at an in-network pharmacy.Save time and money withour mail-order pharmacyGet up to a 3-month supply of Tier1 generic prescription drugs at nocost or a 3-month supply of Tier2, 3, and 4 drugs for the cost of a2-month supply — and have yourprescription delivered to your doorstep in as few as 1 to 2 days at nocost to you.139s2022 Plans and BenefitssWe make sure you have access to appropriate,safe, and effective prescription drugs. That’swhy almost all our plans include Part Dprescription drug coverage.12
Dental benefitsDental care is an important part of stayinghealthy. That’s why Kaiser Permanenteteamed up with Delta Dental of Washingtonto offer the option of adding the DeltaDental PPO Plus Premier plan to any KaiserPermanente Medicare Advantage healthplan.7 And on select plans, we includepreventive dental care benefits.Optional Delta Dental PPO PlusPremier planFor total health support, you have the optionof enrolling in the Delta Dental PPO PlusPremier plan for comprehensive dentalcoverage when you enroll in our MedicareAdvantage health plan.See pages 15 for plan details.Preventive and diagnosticdental servicesIncluded on our Key plan, this benefit coverspreventive care services when provided byan in-network Delta Dental dentist. Servicescovered include: Oral examinations Bite-wing X-rays Panoramic X-rays or complete seriesX-rays Routine preventive teeth cleaning orperiodontal maintenance Fluoride treatmentsDental reimbursement allowanceWith our Essential, Optimal, and Basic plans,you get a dental allowance to help you payfor dental services provided by anylicensed dental provider.10s2022 Plans and Benefitssu
For more information about benefits, please see your Summary of Benefits.For more information about benefits, please see your Summary of Benefits.Plans and Benefits Effective January 1, 2022, through December 31, 2022Plans also available in Kitsap and Lewis counties, and select ZIP codesin Grays Harbor and Mason counties14Plans available in King, Pierce, Snohomish, and Thurston counties Kaiser Permanente Medicare Advantage Key (HMO)Kaiser Permanente Medicare Advantage Vital (HMO)Kaiser Permanente Medicare Advantage Essential (HMO)Kaiser Permanente Medicare Advantage Optimal (HMO)Kaiser Permanente Medicare Advantage Basic (HMO) - Part D not included Kaiser Permanente Medicare Advantage Vital (HMO)Kaiser Permanente Medicare Advantage Essential (HMO)Kaiser Permanente Medicare Advantage Optimal (HMO)Kaiser Permanente Medicare Advantage Basic (HMO) - Part D not includedKey planNot available in Kitsap,Lewis, Grays Harbor, andMason countiesVital planEssential planOptimal planBasic planMonthly Premium 0 29 99 296 40Annual Maximum Out-of-Pocket 6,600 5,800 4,800 3,450 4,200Annual Medical DeductibleNoneNoneNoneNoneNonePart D Prescription DrugCoverageCovered(see page 14 for details)Covered(see page 14 for details)Covered(see page 14 for details)Covered(see page 14 for details)Part D is not included15Doctor Office Visit 10 copay per visit with Primary 50 copay per visit with Specialist 5 copay per visit with Primary 35 copay per visit with Specialist 5 copay per visit with Primary 35 copay per visit with Specialist 0 copay per visit with Primary 20 copay per visit with Specialist 0 copay per visit with Primary 30 copay per visit with SpecialistVirtual Care524-hour consulting nurse, phoneappointments, Care Chat, videovisits, e-visits, secure email fornonurgent questionsNo chargeNo chargeNo chargeNo chargeNo chargeEmergency Room 90 copay 90 copay 90 copay 120 copay 90 copayUrgent Care 40 copay 25 copay 25 copay 25 copay 25 copayPreventive Services6Includes annual physical examNo chargeNo chargeNo chargeNo chargeNo charge11s2022 Plans and Benefitss(continues on next page)
For more information about benefits, please see your Summary of Benefits.For more information about benefits, please see your Summary of Benefits.Plans and Benefits (continued)This plan does not include Part Dprescription drug coverage.Key planNot available in Kitsap,Lewis, Grays Harbor, andMason countiesVital planEssential planOptimal planBasic planInpatient Hospitalization 400 per day for days 1–4 0 for the rest of your stay 325 per day for days 1–5 0 for the rest of your stay 260 per day for days 1–4 0 for the rest of your stay 200 per day for days 1–2 0 for the rest of your stay 200 per day for days 1–3 0 for the rest of your stayOutpatient Surgery 275 copay 250 copay 215 copay 150 copay 200 copaySkilled Nursing FacilityUp to 100 days per benefit period 0 per day for days 1–20 160 per day for days 21–100 0 per day for days 1–20 160 per day for days 21–100 0 per day for days 1–20 115 per day for days 21–100 0 per day for days 1–20 50 per day for days 21–100 0 per day for days 1–20 50 per day for days 21–100Lab, X-ray, Imaging 0-15 lab per visit, 10 X-ray per visit, 275 per visit for MRI, PET,CT scans 0-15 lab per visit, 0 X-ray per visit, 250 per visit for MRI, PET,CT scans 0 lab per visit, 0 X-ray per visit, 200 per visit for MRI, PET,CT scans 0 lab per visit, 0 X-ray per visit, 50 per visit for MRI, PET,CT scans 0 lab per visit, 0 X-ray per visit, 200 per visit for MRI, PET,CT scansDurable Medical Equipment20% coinsurance20% coinsurance20% coinsurance20% coinsurance20% coinsuranceAmbulance Service 250 copay 250 copay 200 copay 100 copay 150 copayChiropractic CareChiropractic coverage forspinal manipulations 20 copay 20 copay 20 copay 10 copay 20 copayBenefits beyond Original Medicare 10 copay per visitwith an optometrist 5 copay per visitwith an optometrist 5 copay per visitwith an optometrist 0 copay per visitwith an optometrist 0 copay per visitwith an optometrist 50 copay per visitwith an ophthalmologist 35 copay per visitwith an ophthalmologist 35 copay per visitwith an ophthalmologist 20 copay per visitwith an ophthalmologist 30 copay per visitwith an ophthalmologist Eyewear allowance 200 allowanceper calendar year 250 allowanceper calendar year 300 allowanceper calendar year 350 allowanceper calendar year 350 allowanceper calendar yearHearing aid allowanceNot covered 750 annual combined 950 annual combined 1,500 annual combined 1,500 annual combined(continues on next page)12s2022 Plans and BenefitssVision Services Routine eye exam
For more information about benefits, please see your Summary of Benefits.For more information about benefits, please see your Summary of Benefits.Benefits beyond Original Medicare (continued)This plan does not include Part Dprescription drug coverage.Key planNot available in Kitsap,Lewis, Grays Harbor, andMason countiesVital planEssential planOptimal planBasic planPreventive DentalCoverage for preventive anddiagnostic services provided byDelta Dental of Washington 400 annual maximumNot coveredNot coveredNot coveredNot coveredDental Reimbursement AllowanceNot coveredNot covered 100 per year 200 per year 200 per yearOver-the-Counter (OTC)Wellness9Coverage for health andwellness products 40 benefit limit per quarter 50 benefit limit per quarterNot coveredNot coveredNot coveredAlternative TherapiesCoverage for routine acupunctureand chiropractic care (non-spinalservices)Not covered 10 copay per acupuncture visit, 20 copay per chiropractic visit,10 visits per year combined 10 copay per acupuncture visit, 20 copay per chiropractic visit,6 visits per year combined 10 copay per acupuncture,chiropractic or naturopathy visit,15 combined total visits per year 10 copay per acupuncture visit, 20 copay per chiropractic visit,15 visits per year combinedTransportationNon-emergency trips to and frommedical and dental appointments 0 for up to 6 round tripsper calendar year 0 for up to 8 round tripsper calendar year 0 for up to 6 round tripsper calendar year 0 for up to 12 round tripsper calendar year 0 for up to 12 round tripsper calendar yearCare While Traveling3Access to care at KaiserPermanente facilities inother regions and with selectproviders in Arizona’s Pimaand Maricopa countiesIncluded; plan benefit costshares applyIncluded; plan benefit costshares applyIncluded; plan benefit costshares applyIncluded; plan benefit costshares applyIncluded; plan benefit costshares applyIncludedIncluded with additionalexpanded network accessIncluded with additionalexpanded network accessIncluded with additionalexpanded network accessIncluded13s2022 Plans and BenefitssFitness ProgramsThe Silver&Fit program10Healthy aging and exerciseprogram offering home fitnesskits, fitness center membership,and more Oral examination Bite-wing X-ray Panoramic X-ray orcomplete series Routine preventive teethcleaning or periodontalmaintenance Fluoride treatments
For more information about benefits, please see your Summary of Benefits.For more information about benefits, please see your Summary of Benefits.Part D Prescription Drug CoverageNOTE: Kaiser Permanente Medicare Advantage Basic (HMO) plan does not include Part D.Key planNot available in Kitsap, Lewis, Grays Harbor,and Mason countiesPrescription Drug Deductible 100 deductibleVital, Essential, Optimal plansNo deductibleInitial Coverage Stage(for up to a 30-day supply)When the annual total drug costs paid byyou and your Part D plan reach 4,430,you move into the Coverage Gap Stage.Coverage Gap Stage(for up to a 30-day supply)Copays for Tier 1 and Tier 2 generics,and injectable Part D vaccines will carryinto the Coverage Gap Stage.If your annual out-of-pocket costs reach 7,050, you move into the CatastrophicCoverage Stage.Catastrophic Coverage StageWhen your annual out-of-pocket costsreach 7,050, you pay lower cost sharesfor the remainder of the calendar year.Mail-Order Pharmacy13(restrictions & limitations may apply)Tier 1 – 3 preferred genericTier 2 – 12 genericTier 3 – 47 preferred brandTier 4 – 99 non-preferred brandTier 5 – 31% coinsurance specialtyTier 6 – 0 injectable Part D vaccinesTier 1 – 3 preferred genericTier 2 – 7 genericTier 3 – 45 preferred brand for Essential & Optimal plans- 47 preferred brand for Vital planTier 4 – 99 non-preferred brandTier 5 – 33% coinsurance specialtyTier 6 – 0 injectable Part D vaccinesYou pay no more than:You pay no more than:Tier 1 – 3 preferred genericTier 2 – 12 genericTier 6 – 0 injectable Part D vaccinesTier 1 – 3 preferred genericTier 2 – 7 genericTier 6 – 0 injectable Part D vaccines25% generic drugs in all other tiers25% brand and non-generic specialty25% generic drugs in all other tiers25% brand and non-generic specialtyYou pay the greater of: 3.95 or 5% for preferred generics,generics, and generic specialtyYou pay the greater of: 3.95 or 5% for preferred generics,generics, and generic specialtyYou pay the greater of: 9.85 or 5% for brand name drugsand non-generic specialty drugsYou pay the greater of: 9.85 or 5% for brand name drugsand non-generic specialty drugs 0 Tier 1 preferred generic for a 31-90 day supply 90-day supply for the cost of a 60-day supply on Tiers 2-4 Specialty and vaccine Tiers, limited to a 30-day supply 0 Tier 1 preferred generic for a 31-90 day supply 90-day supply for the cost of a 60-day supply on Tiers 2-4 Specialty and vaccine Tiers, limited to a 30-day supply14s2022 Plans and BenefitssDeductible is waived on Tiers 1, 2, and 6. You pay thefull cost of your Tier 3, 4, and 5 drugs until you’ve metthe Part D Deductible.
For more information about benefits, please see your Summary of Benefits.Dental benefits by Delta Dental of WashingtonOptional Delta Dental PPO Plus Premier plan7Enhance your health plan by adding the optional supplemental dental plan by DeltaDental of Washington for comprehensive dental coverage. This plan offers access toa large national network of participating providers and no waiting periods for coveredservices. For the most current listing of Delta Dental PPO Plus Premier participatingdentists, visit www.DeltaDentalWA.com or call 1-800-554-1907, Monday throughFriday, 7 a.m. to 5 p.m. Pacific time.Add on to any planOptional Dental Monthly Premium 54 in addition to your monthly plan premiumDeductible 100 per calendar year(waived on preventive and diagnostic care)Annual Benefit Maximum 1,500 per calendar yearPreventive and Diagnostic CareCovered at 100%You pay 0Routine exams and cleanings(2 per calendar year)Fluoride treatment(2 per calendar year)Periodontal cleaningsDental X-raysBasic Dental ExpensesFillings/posterior compositeCovered at 80%You pay 20%Stainless steel crownsOral surgeryEndodontics(i.e., root canal treatment)PeriodonticsCrowns, implants, and onlaysDentures, bridges, and partialsDenture adjustments and relinesCovered at 50%You pay 50%15s2022 Plans and BenefitssMajor Expenses
For more information about benefits, please see your Summary of Benefits.ss2022 Plans and Benefits 16
ENDNOTES1 June 2021 Kaiser Permanente internal data.2 Washington Health Alliance 2021 Community Checkup report, www.wacommunitycheckup.org; rankingapplies to Kaiser Permanente Washington’s medical group, Washington Permanente Medical Group, P.C.3 Member cost shares may apply depending on the service accessed. Referrals and preauthorizationrequirements may apply.4 If you get urgent care at a CVS MinuteClinic within a state with Kaiser Permanente providers, you’ll beasked to pay up front for services you receive and will need to file a claim for reimbursement.5 When appropriate and available. If you travel out of state, virtual care could be limited due to state lawsthat may prevent doctors from providing care across state lines. Laws differ by state.6 0 copay for all preventive services covered under Original Medicare at zero cost sharing.7 If you want the optional dental benefits, you must sign up for these benefits and pay an additionalpremium for them.8 Limitations may apply.9 This benefit cannot be used at Kaiser Permanente pharmacies or retail pharmacies.10 The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of AmericanSpecialty Health Incorporated (ASH). All programs and services are not available in all areas. Other namesor logos may be trademarks of their respective owners. Participating facilities and fitness chains may varyby location and are subject to change. Kits are subject to change and once selected cannot be exchanged.New member initiation fees may apply for select fitness locations in the expanded network. Only onemembership per month is allowed at the following facilities: YMCAs of Pierce, Kitsap, Thurston or GreaterSeattle; Olympic Athletic Club; and West Seattle Health Club.11 Not intended to replace treatment or advice. myStrength is a trademark of Livongo Health, Inc., a whollyowned subsidiary of Teladoc Health, Inc.12 The Basic plan does not include Part D coverage.13 For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-orderpharmacy. You should receive your medicine within 3 to 5 days. If not, please call 1-800-245-7979(TTY 711), Monday through Friday, 7:30 a.m. to 7 p.m., Saturday and Sunday, 8 a.m. to 4:30 p.m.14Grays Harbor County ZIP codes 98541, 98557, 98559, and 98568; Mason County ZIP codes: 98524, 98528,98546, 98548, 98555, 98584, 98588, and 9859217s2022 Plans and Benefitss15 This plan cannot be combined with a stand-alone Part D plan. A gap in Creditable Prescription Drugcoverage may result in future Part D Late Enrollment Penalties.
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CONTACT USProspective members1-800-446-8882TTY WA Relay 1-800-833-6388 or 7118 a.m. to 8 p.m., 7 days a weekCurrent membersMember Services 1-888-901-4600TTY WA Relay 1-800-833-6388 or 7118 a.m. to 8 p.m., 7 days a weekkp.org/wa/medicareKaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente dependson contract renewal. You must reside in the Kaiser Permanente Medicare health plan service area in whichyou enroll.Out-of-network/non-contracted providers are under no obligation to treat Kaiser Permanente members,except in emergency situations. Please call our Member Services number or see your Evidence of Coveragefor more information, including the cost-sharing that applies to out-of-network services. 2021 Kaiser Foundation Health Plan of WashingtonPlease recycle.sMA0002036-53-2119
Dental PPO Plus Premier plan. to any Kaiser Permanente Medicare Advantage health plan. 7. And on select plans, we include . preventive dental care beneits. Optional Delta Dental PPO Plus Premier plan . For total health support, you have the option of enrolling in the Delta Dental PPO Plus Premier plan for . comprehensive dental coverage
