Kaiser Permanente Dual Essential Plan 1 MD (HMO D-SNP)
Available to residents of Prince George's County, MD for 2026. Contract H2172, plan 018, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Prince George's County
- Plan website
- Browse the Kaiser Permanente Dual Essential Plan 1 MD (HMO D-SNP) formulary
New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $200.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H2172-018-0 |
| Offered by | Kaiser Permanente |
| Parent organization | Kaiser Foundation Health Plan, Inc. |
| Formulary drugs | 3,355 |
| Formulary exception tier | 5? |
| Pharmacy search | kp.org/directory |
| Member services | (877)408-8607TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2172 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay(authorization and referral required) |
| Other health care professional | $0–$30 copay(authorization and referral required) |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay(authorization and referral required) |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0 copay(authorization and referral required) |
| Lab services | $0 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $25–$250 copay(authorization and referral required) |
| Therapeutic radiology | $30 copay(authorization and referral required) |
| Outpatient x-rays | $25 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $115 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $115 copay |
| Worldwide urgent care | $30 copay |
| Worldwide emergency transportation | $290 copay |
| Hospital care | |
| Inpatient hospital stay | $375 per day for days 1–5; $0 per day for days 6–90; $0 per day for days 91–999 (additional days)(authorization and referral required) |
| Outpatient hospital services | $0–$350 copay(authorization and referral required) |
| Outpatient observation | $0–$350 copay(authorization required) |
| Ambulatory surgical center | $350 copay(authorization and referral required) |
| Outpatient blood services | $0 copay(authorization and referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization and referral required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance(authorization and referral required) |
| Rehabilitation | |
| Occupational therapy | $30 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $30 copay(authorization and referral required) |
| Cardiac rehabilitation | $30 copay(authorization and referral required) |
| Pulmonary rehabilitation | $25 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $375 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient mental health, individual session | $15 copay(authorization required) |
| Outpatient mental health, group session | $0 copay(authorization required) |
| Psychiatrist, individual session | $15 copay(authorization and referral required) |
| Psychiatrist, group session | $0 copay(authorization and referral required) |
| Partial hospitalization | $15 copay(authorization and referral required) |
| Intensive outpatient program | $15 copay(authorization and referral required) |
| Outpatient substance use, individual session | $15 copay(authorization and referral required) |
| Outpatient substance use, group session | $0 copay(authorization and referral required) |
| Opioid treatment program | $30 copay(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $290 copay(authorization required) |
| Air ambulance | $290 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 0% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $0 copay(authorization and referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $30 copay(authorization and referral required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay(authorization and referral required) |
| Preventive dental plan limit | $1,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $0–$30 copay(authorization and referral required) |
| Routine eye exam | $0–$30 copay(authorization and referral required) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(authorization and referral required, limits apply) |
| Eyewear plan limit | $250 plan limit every two years |
| Contact lenses | $0 copay(authorization and referral required, limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(authorization and referral required, limits apply) |
| Eyeglass lenses | $0 copay(authorization and referral required, limits apply) |
| Eyeglass frames | $0 copay(authorization and referral required, limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay(authorization and referral required) |
| Routine hearing exam | Not covered |
| Hearing aid fitting and evaluation | $0 copay(authorization and referral required) |
| Hearing aid plan limit | $1,000 plan limit every three years |
| Hearing aids (all types) | $0 copay(authorization and referral required, limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $0 copay(authorization required) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required) |
| Other Part B drugs | 0%–20% coinsurance(authorization required) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $30 allowance every month |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay(authorization and referral required) |
| Health education | $0 copay(authorization and referral required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(authorization and referral required) |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | $0 copay(authorization and referral required) |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | 0% |
| Tier 2 | 0% |
| Tier 3 | 5% |
| Tier 4 | 25% |
| Tier 5 | 25% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | 0% | 25% | 0% | 0% | 25% | 0% |
| Tier 2: Generic | 0% | 25% | 0% | 0% | 25% | 0% |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | n/a | n/a | n/a |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | 0% | 25% | 0% | 0% | 25% | 0% |
| Tier 2: Generic | 0% | 25% | 0% | 0% | 25% | 0% |
| Tier 3: Preferred Brand | 5% | 25% | 5% | 5% | 25% | 5% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 4 other MD counties
Benefits in plain text
Kaiser Permanente Dual Essential Plan 1 MD (HMO D-SNP) (H2172-018-0) is a 2026 HMO D-SNP Medicare Advantage plan offered by Kaiser Permanente, available to residents of Prince George's County, MD.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $200.00. Tier 1, 2 and 6 exempt.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,355 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: 0%; tier 2: 0%; tier 3: 5%; tier 4: 25%; tier 5: 25%; tier 6: $0.00.
CMS gives the plan's contract (H2172) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.