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Rx Select (HMO-POS) 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.
2021 Medical Benefits
2021 Plan Premiums
2021 Prescription Benefits
KelseyCare Advantage Rx Select provides Part D prescription drug coverage in addition to the medical benefits of Medicare Parts A and B. This plan also offers a point-of-service benefit.
With this plan, you have the option of accessing certain specialists who are in or out of the KelseyCare Advantage provider network.
Who Should Join?
The KelseyCare Advantage Rx Select 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. The Rx Select plan offers members the option to access certain specialists who are outside of the KelseyCare Advantage provider network.
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?
The monthly plan premium to enroll in the Rx Select plan is $15.00. Additionally, 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.
KelseyCare Advantage Rx Select 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 use specialists who are in or out of the KelseyCare Advantage provider network. The health providers in our network can change at any time. Members can elect to have their Kelsey-Seybold Clinic physician “coordinate” their care or they can choose to “self-refer” for care from certain specialists outside of Kelsey-Seybold Clinic. Members receive a higher level of benefits and pay lower out-of-pocket costs when they use in-network providers.