to main content

2020 Benefits Summary

This is a summary of what our plan covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage, this legal member contract is the primary source of the coverage information and supersedes all other information.

  • Medical Benefits
  • Prescription Drug Benefits
  • Premium
Covered Service What You Pay
PHYSICIAN SERVICES / DOCTOR OFFICE VISITS
PCP - $0
Specialist - $35
ANNUAL WELLNESS VISIT $0
TELEHEALTH BENEFIT
E-Visit PCP- $0
E-Visit Spec - $0
Video Visit PCP - $0
Video Visit Spec - $35
PREVENTIVE HEATLH SCREENINGS $0
INPATIENT HOSPITAL CARE $500  per admission
SKILLED NURSING FACILITY CARE (SNF) $0/day - days 1-20
$125/day - days 21-100
OUTPATIENT DIAGNOSTIC TESTS AND THERAPUTIC SERVICES & SUPPLIES Diagnostic labs & x-rays $0
Cardiac Stress Test - $25
Advanced Radiology - $150
MRI - $150
PET scan - $150
Radiation Th, IMRT - $50
EMERGENCY CARE $120
AMBULANCE SERVICES $100
URGENTLY NEEDED SERVICES $25
OUTPATIENT HOSPITAL OBSERVATION $300
OUTPATIENT HOSPITAL SERVICES ASC - $225 
Hospital $300
OUTPATIENT SURGERY
ASC - $225
Hospital - $300
OUTPATIENT REHAB SERVICES PT and OT - $10
Speech - $35
Wound Care/Lymphedema - $35
OUTPATIENT MENTAL HEALTH CARE Group - $20
Individual - $35
OUTPATIENT SUBSTANCE ABUSE SERVICES Group - $20 
Individual  - $35
DURABLE MEDICAL EQUIPMENT (DME) AND RELATED SUPPLIES 20% coinsurance
PROSTHETIC DEVICES AND RELATED SUPPLIES 20% coinsurance
MEDICARE PART B PRESCRIPTION DRUGS 20% coinsurance
(Including chemotherapy)
SERVICES TO TREAT KIDNEY DISEASE $25 for renal dialysis treatment
$0 for education services
PULMONARY REHABILITATION SERVICES $30
CARDIAC REHABILITATION SERVICES $35
CHIROPRACTIC SERVICES $20
PODIATRY SERVICES
$35
HOME HEALTH AGENCY CARE $10
INPATIENT MENTAL HEALTH CARE $500 per admission
MEDICAL NUTRITION THERAPY $0
DENTAL SERVICES 20% coinsurance - Medicare covered 
DIABETES SELF MGMT TRAINING, DIABETIC SERVICES AND SUPPLIES
0% for testing supplies
20% for diabetic shoes & inserts
20% for insulin pump & supplies
IMMUNIZATIONS $0
TRANSPORTATION $0
SMOKING CESSATION $0
HEARING SERVICES
Diagnostic - $35
Routine- $35
Hearing Aid Fitting- $35
$125 plan allowance per year
VISION CARE Diagnostic - $35
Routine- $0
$75 plan allowance per year
This table gives you basic information about the prescription drug benefits that are available with some of our plans. For more details, see the Comprehensive Formulary (PDF) in the Plan Documents section.
 

Initial Coverage

You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan’s deductible amount.  After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,020. Total yearly drug costs are the total drug cost paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
 
Preferred Retail Cost-Sharing

Tier One-month supply Three-month supply
Tier 1 (Preferred Generic)  $3 copay  $7.50 copay
Tier 2 (Generic)
 $5 copay  $12.50 copay
Tier 3 (Preferred Brand)
 $40 copay  $100 copay
Tier 4 (Non-Preferred Brand)
 $60 copay  $150 copay
Tier 5 (Specialty Tier)
 31% of the cost  A long-term supply is not available for drugs in Tier 5 Specialty.

 
Standard Retail Cost-Sharing

 Tier One-month supply Three-month supply
 Tier 1 (Preferred Generic)  $8 copay  $24 copay
 Tier 2 (Generic)  $10 copay  $30 copay
 Tier 3 (Preferred Brand)  $45 copay  $135 copay
 Tier 4 (Non-Preferred Brand)  $70 copay  $210 copay
 Tier 5 (Specialty Tier)  31% of the cost  A long-term supply is not available for drugs in Tier 5 Specialty
 
 Stage Description
 Coverage Gap Stage  Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.

After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you.
 Catastrophic Coverage Stage  After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:
  • 5% of the cost, or
  • $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs. 
 

Plan Premium

The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government.   
Plan Monthly Premium
Rx $0

Plan Summaries

KelseyCare Advantage Rx provides Medicare Part D prescription drug coverage in addition to the medical benefits of Medicare Parts A and B.

Who Should Join?

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 worldwide emergency coverage as well as coverage for routine vision, hearing, and medical transportation.

You Must:

1.  Be eligible for Medicare Part A and enrolled in Part B,
2.  Continue to pay Part B premiums,
3.  Live in the plan service area, and
4.  Not have End-Stage Renal Disease (permanent kidney failure).

How Much Does it Cost?

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 any Medicare Advantage plan. Most people will pay the standard Part B premium amount. Please call Social Security at 1-800-772-1213 for information about your Part B premium.

Provider Network

KelseyCare Advantage Rx members will receive most of their medical care from the doctors at Kelsey-Seybold Clinic. KelseyCare Advantage also contracts with an affiliate network of doctors to provide care that is not offered at Kelsey-Seybold. 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.

X
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.
Confirm