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What You Pay
Physician Services/Doctor Office Visits
PCP - $0
Annual Wellness Visit
E-Visit PCP - $0
E-Visit Specialist - $15
Video Visit PCP - $0
Video Visit Specialist - $15
Preventive Health Screenings
Inpatient Hospital Care
$300 per admission
No limit to the number of days covered
Skilled Nursing Facility (SNF)
$0/Day - Days 1-20
$100/ Day - Days 21-100
Outpatient Diagnostic Tests and Therapeutic Services & Supplies
Diagnostic labs & x-rays - $0
Cardiac Stress Test - $25
Advanced Radiology - $100
MRI - $100
PET Scan - $100
Radiation Therapy, IMRT - $15
Urgently Needed Services
Outpatient Hospital Observation
Outpatient Hospital Services
ASC - $150
ASC - $150
Outpatient Rehab Services
PT and OT - $15
Speech - $15
Would Care/Lymphedema - $15
Outpatient Mental Health Care
Individual or Group - $20
Outpatient Substance Abuse Services
Individual or Group - 20
Durable Medical Equipment (DME) and related Supplies
20% meters, test strips, lancets, lancet devices and control solutions
All other DME is 10% coinsurance
Prosthetic Devices and Related Supplies
Medicare Part B Prescription Drugs
15% coinsurance (including chemotherapy)
Services to Treat Kidney Disease
$0 for education services
Pulmonary Rehabilitation Services
Cardiac Rehabilitation Services
Home Health Agency Care
Inpatient Mental Health Care
$300 per admission
Medical Nutrition Therapy
$0 - Medicare Covered
Diabetes Self Management Training, Diabetic Services and Supplies
20% for diabetic shoes & inserts
10% for insulin pump & supplies
$0 (20 one-way trips per year)
Diagnostic - $15
Routine - $0
Hearing Aid Fitting - $15
Diagnostic - $0
Routine - $0
$200 plan allowance per year
Eligibility and Service Area
You are eligible for membership in our plan as long as you:
Have both Medicare Part A and Medicare Part B
and you live in our geographic service area (listed below)
and you are a United States citizen or are lawfully present in the United States
and you meet the eligibility requirements of the sponsor of the City of Houston.
You must reside in one of the following counties to be eligible for this plan:
Prescription Drug Information
2023 Drug Search – See if your drug is covered
Click here to search the 2023 City of Houston KelseyCare Advantage Formulary.
2023 Schedule of Copayments for Prescription Drugs
Your pharmacies with preferred cost-sharing include Kelsey Pharmacies, H-E-B, CVS retail pharmacies and CVS Mail Service Pharmacy. If you fill your prescription at these pharmacies, you may pay lower cost sharing than at other pharmacies.
Preferred Retail and Mail Order Pharmacies
Standard Retail Pharmacy (Non-Preferred)
Value Added Benefits
Free Gym Membership access through SilverSneakers. SilverSenakers gives you a variety of ways to keep moving and connect with others.
SilverSneakers Live. Join full-length, live classes and workshops on the SilverSneakers website via Zoom. Multiple activities led by expert trainers are available per day, and no equipment is needed.
SilverSneakers On-Demand. Access 200+ online workout videos, plus information on topics like nutrition, fitness challenges and more. Go to SilverSneakers On-Demand to view videos.
SilverSneakers GO mobile app. Find workout programs that can be tailored to your fitness levels, schedule activities and get notifications to stay on track. Download the app today at SilverSneakers GO.
Memberships to thousands of participating locations. Visit as many as you want to use equipment, pools, and other amenities, and take group execise classes at select locations. Find locations here.
$200 allowance each year towards the purchase of contacts or lenses.
KelseyCare Advantage plans include vision benefits through Vision Services Providers (VSP) which provides coverage for routine eye exams and diagnosis and treatment of eye diseases and injuries, and some allowance for glasses and contacts.
20 one-way trips each year for transportation to medical appointments. We understand that transportation to and from medical appointments is an important benefit for many members. KelseyCare Advantage offers free Medicare transportation benefits.
Virtual Health and MyKelseyOnline
Video and E-Visits with a Kelsey PCP covered at $0 copay. Specialist virtual health visits $15. Correspond with your providers, view test results, schedule appointment through your secure patient portal. For more information visit MyKelseyOnline.