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Rx (HMO) Plan

2021 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.

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.

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.

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