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Kaiser Permanente Medicare Advantage Essential Pce (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage Essential Pce (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Kaiser Permanente Medicare Advantage Essential Pce (HMO) in 2026, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage Essential Pce (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2026 to people living in Pierce. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Kaiser Permanente Medicare Advantage Essential Pce (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Kaiser Permanente Medicare Advantage Essential Pce (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Kaiser Permanente Medicare Advantage Essential Pce (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $69.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4950.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Kaiser Permanente Medicare Advantage Essential Pce (HMO) features a $0 drug deductible, meaning your prescription coverage begins immediately. For Tier 1 preferred generics, you will pay no copay through standard mail order, while preferred pharmacies offer copays starting at $2 for a one-month supply. Tier 2 generics cost $10 for a one-month supply at preferred pharmacies, but you can pay no copay for two- or three-month supplies filled via standard mail order. Tier 3 preferred brands and Tier 4 non-preferred drugs require a $47 and $99 copay respectively for a one-month supply at both preferred and standard pharmacies. Specialty medications in Tier 5 carry a 31% coinsurance across all pharmacy options, while Tier 6 vaccines are available with no copay for a one-month supply. This plan provides cost-effective prescription drug coverage, particularly when utilizing standard mail-order options for generic medications.
Additional Benefits
The Kaiser Permanente Medicare Advantage Essential Pce (HMO) offers comprehensive coverage with no copay for primary care, telehealth, preventive services, and diagnostic lab tests. For hospital care, patients pay a $350 daily copay for the first five days of inpatient stays and no copay thereafter, while emergency services require a $130 copay. Specialist visits and therapy services are highly affordable, with copays ranging from no copay to $35. Supplemental benefits include preventive dental care with no copay and routine eye exams alongside a $300 annual eyewear allowance. However, certain services like dialysis and durable medical equipment require a 20% coinsurance, and hearing aids, acupuncture, and over-the-counter items are not covered. This plan provides a well-rounded balance of low-cost routine care and structured costs for major medical services.
Inpatient Hospital See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $350 daily copay for days 1 through 5 and no copay for days 6 through 90. While unlimited additional acute days are covered with no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers outpatient services with no coinsurance, featuring copays ranging from $0 to $340 for outpatient hospital, observation, and ambulatory surgical center services. Outpatient substance abuse sessions require a $25 or $35 copay, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Kaiser Permanente Medicare Advantage Essential Pce (HMO) plan with a $140.00 copay and no coinsurance. Both prior authorization and a referral are required to receive these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Kaiser Permanente Medicare Advantage Essential Pce (HMO), offering ground and air ambulance services for a $290 copay per service with no coinsurance. Prior authorization is required for ambulance services, and transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by Kaiser Permanente Medicare Advantage Essential Pce (HMO) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $30 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with copays of $130, $30, and $290 respectively, and no coinsurance.
Primary Care See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) provides primary care and telehealth services with no copay and no coinsurance, while specialist, psychiatric, and therapy services require copays between $0 and $35 with no coinsurance. Routine chiropractic care is covered with a $15 copay and no coinsurance, but other chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under the Kaiser Permanente Medicare Advantage Essential Pce (HMO) plan, featuring no copay and no coinsurance for covered services like annual physical exams, fitness benefits, and select screenings. However, the plan does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by Kaiser Permanente Medicare Advantage Essential Pce (HMO), which offers Medicare-covered exams, annual routine exams, and fitting evaluations with no deductible, no coinsurance, and copays ranging from no copay to $35. However, prescription hearing aids and over-the-counter hearing aids are not covered.
Vision Services See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) offers partially covered vision services with no deductibles or coinsurance. Routine eye exams are covered with a $0 to $35 copay (one per year), and eyewear is covered with no copay up to a $300 annual maximum, though other eye exam services and eyewear upgrades are not covered.
Dental Services See details
Dental services are partially covered by the Kaiser Permanente Medicare Advantage Essential Pce (HMO) plan, which offers Medicare-covered dental care for a $35 copay and no coinsurance, and preventive services with no copay and no coinsurance. While restorative, periodontic, and oral surgery services are covered, implant services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while Part B chemotherapy and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization and a referral are required to receive these covered services.
Medical Equipment See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic supplies and therapeutic shoes are also covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers diagnostic procedures and lab services with no copay and no coinsurance. Diagnostic radiological services require a $325 copay, therapeutic radiological services have a 20% coinsurance, and outpatient X-rays require a $10 copay, with prior authorization and referrals required for these services.
Home Health Services See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers home health services with no copay and no coinsurance. Prior authorization and a referral are required to access this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered with no coinsurance by the Kaiser Permanente Medicare Advantage Essential Pce (HMO), but only some services are covered. Specifically, the plan does not cover cardiac rehabilitation ($35 copay), intensive cardiac rehabilitation ($35 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($25 copay).
Skilled Nursing Facility (SNF) See details
Kaiser Permanente Medicare Advantage Essential Pce (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization and a referral. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Kaiser Permanente Medicare Advantage Essential Pce (HMO), as acupuncture, over-the-counter (OTC) items, and meal benefits are excluded from coverage.
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