1 Dental benefits provided by LIBERTY Dental Plan.
2 With 50% coinsurance. Annual allowance varies by plan option. See your Evidence of Coverage for details.
3 Not available with Kaiser Permanente Medicare Advantage Care Plus VA (HMO-POS), Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS), Kaiser Permanente Medicare Advantage Value Balt (HMO), Kaiser Permanente Medicare Advantage Value MD (HMO), and Kaiser Permanente Medicare Advantage Liberty (HMO) plans. Members are responsible for any charged amounts for covered services that exceed the annual allowance maximum of $1,200. Coverage limited to inside the United States and its territories. See your Evidence of Coverage for details. Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
4 Hearing aid allowance can only be used for hearing aids purchased at Kaiser Permanente audiology centers.
5 Please refer to your Evidence of Coverage for details. OTC benefits may change each year on January 1. Each order must be at least $20. Any unused portion of the quarterly benefit limit will not carry forward to the next quarter. Your order may not exceed your quarterly benefit limit. Limitations and restrictions may apply. Cash, check, credits cards, or money orders are not accepted.
6 OTC allowance based on plan type.
7 Not available with Kaiser Permanente Medicare Advantage Value Balt (HMO), Kaiser Permanente Medicare Advantage Value MD (HMO), or Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plans. One Pass® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions and is a voluntary program. The One Pass program and amenities vary by plan, area, and location. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. One Pass is not responsible for the services or information provided by third parties. Individuals should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for them.
8 Three kits are offered and limited to one a year.
9 Transportation benefits are not available with the following plans: Kaiser Permanente Medicare Advantage Value Balt (HMO), Kaiser Permanente Medicare Advantage Value MD (HMO), Kaiser Permanente Medicare Advantage Value DC (HMO-POS), Kaiser Permanente Medicare Advantage Liberty (HMO), and Kaiser Permanente Medicare Advantage Care Plus MD (HMO-POS). Twenty-four one-way rides per contract year. For nonemergency transportation only.
