Speak With a Member Services Representative
Call 713-442-CARE
Contact Us
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.
You may get your drugs at network retail pharmacies.
Preferred Retail Cost-Sharing
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:
|
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.