KelseyCare Advantage Rx

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This is a Medicare Advantage plan that covers prescription drugs. KelseyCare Advantage Rx provides Part D coverage in addition to the medical benefits of Medicare Parts A and B.

	Description
Plan Summary	The KelseyCare Advantage Rx plan works well for Medicare beneficiaries that need comprehensive coverage and low out of pocket expenses for their hospital, medical and prescription drug benefits. This plan also offers coverage for routine vision, routine hearing and medical transportation.
Eligibility	Be eligible for Medicare Part A and enrolled in Part B, Continue to pay Part B premiums, Live in the plan service area, and Not have end-stage renal disease (permanent kidney failure).
Premium	There is no monthly plan premium to enroll in the Rx plan. However, you must maintain your Medicare Part B coverage to be a member of the Rx plan. Most people will pay the standard premium amount, which is $99.90 in 2012. Please call Social Security at 1-800-772-1213 for information about your Part B premium.
Doctor and Hospital Choice	KelseyCare Advantage Rx has formed a network of doctors, specialists and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. A referral may be required to access some network doctors. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither KelseyCare Advantage Rx nor the Original Medicare plan will pay for these services.
Documents for Download	For a description of the KelseyCare Advantage Rx benefits, download the Summary of Benefits PDF 2012. For comprehensive documentation of the benefits, limitations and exclusions for this plan, download the Evidence of Coverage PDF 2012.

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H0332_WB12001_CMSDateApproved_10/18/2011
Last Updated: 10/1/11

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KelseyCare Advantage Rx

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