KelseyCare Advantage Rx
Summary of Benefits

Important Information

1 - Premium and Other Important Information

In 2011, the monthly Part B Premium is $110.50 and the yearly Part B deductible amount is $162.

If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more.

Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE 1-800-633- 4227). TTY users should call 1- 877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

General

$0 monthly plan premium in addition to your monthly Medicare Part B premium.

Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

This plan covers all Medicare- covered preventive services with zero cost sharing.

In-Network

$3,400 out-of-pocket limit.

This limit includes only

Medicare-covered services.

2 - Doctor and Hospital Choice

(For more information, see Emergency - #15 and Urgently Needed Care - #16.)

You may go to any doctor, specialist or hospital that accepts Medicare.

In-Network

You must go to network doctors, specialists, and hospitals.

Referral required for network hospitals and specialists (for certain benefits).

Summary of Benefits

Inpatient Care

3 - Inpatient Hospital Care

(includes Substance Abuse and Rehabilitation Services)

In 2011, the amounts for each benefit period are:

Days 1 - 60: $1,132 deductible

Days 61 - 90: $283 per day

Days 91 - 150: $566 per lifetime reserve day

Call 1-800-MEDICARE

(1-800-633-4227) for information about lifetime reserve days.

Lifetime reserve days can only be used once.

A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

In-Network

No limit to the number of days

covered by the plan each

benefit period

$500 copay for each Medicare-covered hospital stay

$0 copay for additional hospital days

$500 out of pocket limit every stay

Except in an emergency, your

doctor must tell the plan that

you are going to be admitted to

the hospital.

4 - Inpatient Mental Health Care

Same deductible and copay as inpatient hospital care (see “Inpatient Hospital Care” above)

190-day lifetime limit in a Psychiatric Hospital

In-Network

You get up to 190 days in a Psychiatric Hospital in a lifetime.

$500 copay for each Medicare-covered hospital stay

The maximum out-of-pocket limit is covered under “Inpatient Hospital Care”.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

5 - Skilled Nursing Facility (SNF)

(in a Medicare-certified skilled nursing facility)

In 2011, the amounts for each benefit period after at least a 3-day covered hospital stay are:

Days 1 - 20: $0 per day

Days 21 - 100: $141.50 per day

100 days for each benefit period.

A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care.

If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

General

Authorization rules may apply

In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For SNF stays:

Days 1 - 20: $0 copay per day

Days 21 - 100: $125 copay per day

6 - Home Health Care

(includes medically necessary intermittent skilled nursingcare, home health aide services, and rehabilitation services, etc.)

$0 copay

General

Authorization rules may apply

In-Network

$0 copay for Medicare-covered

home health visits

7 - Hospice

You pay part of the cost for outpatient drugs and inpatient respite care.

You must get care from a

Medicare-certified hospice.

General

You must get care from a

Medicare-certified hospice.

Outpatient Care

8 - Doctor Office Visits

20% coinsurance

General

See “Welcome to Medicare and Annual Wellness Visit,” for more information.

Authorization rules may apply

In-Network

$0 copay for each primary care doctor visit for Medicare-covered benefits

$50 copay for each in-area, network urgent care Medicare-covered visit

$15 copay for each specialist visit for Medicare-covered benefits

9 - Chiropractic Services

Routine care not covered

20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

General

Authorization rules may apply

In-Network

$15 copay for each Medicare-covered visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

10 - Podiatry Services

Routine care not covered

20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs

General

Authorization rules may apply

In-Network

$15 copay for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medically necessary foot care.

11 - Outpatient Mental Health Care

45% coinsurance for most outpatient mental health services

General

Authorization rules may apply

In-Network

$35 copay for each Medicare-covered individual therapy visit

$20 copay for each Medicare-covered group therapy visit

12 - Outpatient Substance Abuse

Care

20% coinsurance

General

Authorization rules may apply

In-Network

$35 copay for Medicare-covered individual visits

$20 copay for Medicare-covered group visits

13 - Outpatient Services/Surgery

20% coinsurance for the doctor

Specified copayment for outpatient hospital facility charges. Copay cannot exceed Part A inpatient hospital deductible.

20% copayment for ambulatory surgical center facility charges

General

Authorization rules may apply

In-Network

$175 copay for each Medicare-covered ambulatory surgical center visit

$175 copay for each Medicare-covered outpatient hospital facility visit

14 - Ambulance Services

(medically necessary ambulance services)

20% coinsurance

General

Authorization rules may apply

In-Network

$100 copay for Medicare-covered ambulance benefits

15 - Emergency Care

(You may go to any emergency room if you reasonably believe you need emergency care.)

20% coinsurance for the doctor

Specified copayment for outpatient hospital emergency room (ER) facility charge.

ER copay cannot exceed Part A inpatient hospital deductible.

You don’t have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit.

Not covered outside the U.S. except under limited circumstances.

General

$50 copay for Medicare-covered emergency room visits

Worldwide coverage

If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the emergency room visit

16 - Urgently Needed Care

(This is NOT emergency care, and in most cases, is out of the service area.)

20% coinsurance, or a set copay

NOT covered outside the U.S. except under limited circumstances

General

$50 copay for Medicare-covered urgently needed care visits

17 - Outpatient Rehabilitation Services

(Occupational Therapy, Physical Therapy, Speech and Language Therapy, Respiratory Therapy Services, Social/Psychological Services, and more)

20% coinsurance

General

Authorization rules may apply

In-Network

$15 copay for Medicare-covered Occupational Therapy visits

$15 copay for Medicare-covered Physical and/or Speech/Language Therapy visits

$25 copay for Medicare-covered Cardiac Rehab services

Outpatient Medical Services and Supplies

18 - Durable Medical Equipment

(includes wheelchairs, oxygen, etc.)

20% coinsurance

General

Authorization rules may apply

In-Network

10% of the cost for Medicare-covered items

19 - Prosthetic Devices

(includes braces, artificial limbs and eyes, etc.)

20% coinsurance

General

Authorization rules may apply

In-Network

20% of the cost for

Medicare-covered items

20 - Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies

(includes coverage for glucose monitors, test strips, lancets, screening tests, self-management training, retinal exam/glaucoma test, and foot exam/therapeutic soft shoes)

20% coinsurance

Nutrition therapy is for people who have diabetes or kidney disease (but aren’t on dialysis or haven’t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

General

Authorization rules may apply

In-Network

$0 copay for Diabetes self-monitoring training

$0 copay for nutrition therapy for Diabetes

0% to 10% of the cost for Diabetes supplies

21 - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

20% coinsurance for diagnostic tests and x-rays

$0 copay for Medicare-covered lab services

Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol.

General

Authorization rules may apply

In-Network

$0 copay for Medicare-covered lab services

$0 to $100 copay for Medicare-covered diagnostic procedures and tests

$0 copay for Medicare-covered X-rays

$0 to $100 copay for Medicare-covered diagnostic radiology services (not including x-rays)

$25 copay for Medicare-covered therapeutic radiology services

Preventive Services

22 - Bone Mass Measurement

(for people with Medicare who are at risk)

No coinsurance, copayment or deductible.

Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.

General

Authorization rules may apply

In-Network

$0 copay for Medicare-covered

bone mass measurement

23 - Colorectal Screening Exams

(for people with Medicare age 50 and older)

No coinsurance, copayment or deductible for screening colonoscopy or screening flexible sigmoidoscopy.

Covered when you are high risk or when you are age 50 and older.

General

Authorization rules may apply

In-Network

$0 copay for Medicare-covered colorectal screenings.

25 - Mammograms (Annual Screening)

(for women with Medicare age 40 and older)

No coinsurance, copayment or deductible

No referral needed

Covered once a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39.

In-Network

$0 copay for Medicare-covered screening mammograms

26 - Pap Smears and Pelvic Exams

(for women with Medicare)

No coinsurance, copayment, or deductible for Pap smears

No coinsurance, copayment, or deductible for Pelvic and clinical breast exams

Covered once every 2 years

Covered once a year for women with Medicare at high risk

In-Network

$0 copay for Medicare-covered pap smears and pelvic exams

27 - Prostate Cancer Screening Exams

(for men with Medicare age 50 and older)

20% coinsurance for the digital rectal exam

$0 for the PSA test; 20% coinsurance for other related services

Covered once a year for all men with Medicare over age 50

In-Network

$0 copay for Medicare-covered prostate cancer screening

28 - End-Stage Renal Disease

20% coinsurance for renal dialysis

20% coinsurance for Nutrition Therapy for End-Stage Renal Disease

Nutrition therapy is for people who have diabetes or kidney disease (but aren’t on dialysis or haven’t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

General

Authorization rules may apply

In-Network

$25 copay for renal dialysis

$0 copay for Nutrition Therapy

for End-Stage Renal Disease

29 - Prescription Drugs

Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare

Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

Drugs Covered Under

Medicare Part B

General

10% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.

Drugs Covered Under

Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.kelseycareadvantage. com on the web.

Different out-of-pocket costs may apply for people who

- have limited incomes,

- live in long term care facilities,

or

-

have access to Indian/Tribal/Urban (Indian Health Service).

The plan offers national in-network prescription coverage (i.e., this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and the plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from KelseyCare Advantage Rx (HMO) for certain drugs.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher

cost-sharing amount.

If you request a formulary exception for a drug and KelseyCare Advantage Rx (HMO) approves the exception, you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug.

In-Network

$0 deductible

Initial Coverage

You pay the following until total yearly drug costs reach $2,840:

Retail Pharmacy

Tier 1: Preferred Generic Drugs

-

$3 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy

-

$7.50 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy

-

$8 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy

-

$24 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy

Tier 2: Non-Preferred Generic Drugs

-

$30 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy

-

$75 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy

-

$40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy

-

$120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy

Tier 3: Preferred Brand Drugs

-

$30 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy

-

$75 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy

-

$40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy

-

$120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy

Tier 4: Non-Preferred Brand Drugs

-

$60 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy

-

$150 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy

-

$70 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy

-

$210 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy

Tier 5: Specialty Tier Drugs

-

33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy

-

33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy

-

33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy

-

33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy

Long Term Care Pharmacy

Tier 1: Preferred Generic Drugs

-

$8 copay for a one-month (31-day) supply of drugs in this tier

Tier 2: Non-Preferred Generic Drugs

-

$40 copay for a one-month (31-day) supply of drugs in this tier

Tier 3: Preferred Brand Drugs

-

$40 copay for a one-month (31-day) supply of drugs in this tier

Tier 4: Non-Preferred Brand Drugs

-

$70 copay for a one-month (31-day) supply of drugs in this tier

Tier 5: Specialty Tier Drugs

-

33% coinsurance for a one-month (31-day) supply of drugs in this tier

Additional Coverage Gap

You pay the following:

Retail Pharmacy

Tier 1: Preferred Generic Drugs

-

$3 copay for a one-month (30-day) supply of all drugs covered in this tier from a preferred pharmacy

-

$7.50 copay for a three-month (90-day) supply of all drugs covered in this tier from a preferred pharmacy

-

$8 copay for a one-month (30-day) supply of all drugs covered in this tier at a non-preferred pharmacy

-

$24 copay for a three-month (90-day) supply of all drugs covered in this tier from a non-preferred pharmacy

Long Term Care Pharmacy

Tier 1: Preferred Generic Drugs

-

$8 copay for a one-month (31-day) supply of all drugs covered in this tier

After your total yearly drug costs reach $2,840, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $ 4,550, you pay the greater of:

-

A $ 2.50 copay for generic (including brand drugs treated as generic) and a $6.30 copay for all other drugs,

or

- 5% coinsurance.

Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive

reimbursement from KelseyCare Advantage Rx (HMO).

Out-of-Network Initial Coverage

You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,840:

Tier 1: Preferred Generic Drugs

-

$8 copay for a one-month (30-day) supply of drugs in this tier

Tier 2: Non-Preferred Generic Drugs

-

$40 copay for a one-month (30-day) supply of drugs in this tier

Tier 3: Preferred Brand Drugs

-

$40 copay for a one-month (30-day) supply of drugs in this tier

Tier 4: Non-Preferred Brand Drugs

-

$70 copay for a one-month (30-day) supply of drugs in this tier

Tier 5: Specialty Tier Drugs

-

33% coinsurance for a one-month (30-day) supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following:

Tier 1: Preferred Generic Drugs

-

$8 copay for a one-month (30-day) supply of all drugs covered in this tier

Tier 2: Non-Preferred Generic Drugs

-

You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly drug costs reach $4,550.

You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly drug costs reach $4,550.

Tier 3: Preferred Brand Drugs

-

You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly drug costs reach $4,550.

You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly drug costs reach $4,550.

Tier 4: Non-Preferred Brand Drugs

-

You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly drug costs reach $4,550.

You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly drug costs reach $4,550.

Tier 5: Specialty Tier Drugs

-

You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly drug costs reach $4,550.

You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly drug costs reach $4,550.

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.

Out-of-Network Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share, which is the greater of:

-

A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs,

or

-

5% coinsurance.

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.

29 - Prescription Drugs

30 - Dental Services

Preventive dental services (such as cleaning) not covered

General

Authorization rules may apply

In-Network

In general, preventive dental benefits (such as cleaning) not covered

$15 copay for Medicare-covered dental benefits

31 - Hearing Services

Routine hearing exams and hearing aids not covered

20% coinsurance for diagnostic hearing exams

General

Authorization rules may apply

In-Network

$0 copay for up to 2 hearing aids every two years

$0 copay for Medicare-covered diagnostic hearing exams

$15 copay for up to 1 routine hearing test every year

$15 copay for up to 1 hearing aid fitting evaluation every two years

$600 limit for hearing aids every two years

32 - Vision Services

20% coinsurance for diagnosis and treatment of diseases and conditions of the eye

Routine eye exams and glasses not covered

Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.

Annual glaucoma screenings covered for people at risk

In-Network

$0 copay for diagnosis and treatment for diseases and conditions of the eye

- and up to 1 routine eye exam every year

$0 copay for one pair of eyeglasses or contact lenses after cataract surgery

33 - Welcome to Medicare; and Annual Wellness

Visit

When you join Medicare Part B, then you are eligible as follows:

During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare exam or an Annual Wellness visit.

After your first 12 months, you can get one Annual Wellness visit every 12 months.

There is no coinsurance, copayment or deductible for either the Welcome to Medicare exam or the Annual Wellness visit.

The Welcome to Medicare exam does not include lab tests.

In-Network

$0 copay for routine exams

Limited to 1 exam every year

34 - Health/Wellness Education

Smoking Cessation:

Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco. Each counseling attempt includes up to four face-to-face visits. You pay coinsurance, and Part B deductible applies.

$0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor’s visit. HIV screening is covered for people with Medicare who are pregnant and people at

increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

In-Network

The plan covers the following health/wellness education benefits:

- Written health education materials, including newsletters

- Nutritional Training

- Nursing Hotline

$0 copay for each Medicare-covered smoking cessation counseling session

$0 copay for each medicare covered HIV screening.

HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

Transportation

(Routine)

Not covered

In-Network

$0 copay for up to 20 one-way trips to plan-approved locations every year

Acupuncture

Not covered

In-Network

This plan does not cover Acupuncture.