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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.
Download the Summary of Benefits
Covered Services | What You Pay |
Physician Services / Doctor Office Visits | PCP - $0 Specialist - $25 |
Annual Wellness Visit | $0 |
Telehealth Benefit | PCP - $0 Specialist - $15 |
Preventive Health Screenings | $0 |
Inpatient Hospital Care | $375 per stay |
Skilled Nursing Facility Care (SNF) | $0/day - days 1-20 $125/day - days 21-100 |
Outpatient Diagnostic Tests and Therapeutic Services & Supplies | Diagnostic labs & x-rays $0 Advanced Radiology - $150 |
Emergency Care | $120 |
Ambulance Services | $225 |
Urgently Needed Services | $25 |
Convenient Care | Per visit: $25 CVS Minute Clinics only |
Over-the-Counter Items (OTC) | $25 every quarter |
Outpatient Hospital Observation | $300 |
Outpatient Surgery | ASC - $225 Hospital $300 |
Outpatient Rehab Services | PT and OT - $10 Speech - $35 |
Outpatient Mental Health Care | Individual or Group - $20 |
Outpatient Substance Abuse Services | Individual or Group - $20 |
Durable Medical Equipment (DME) and Related Supplies | 15-20% |
Prosthetic Devices and Related Supplies | 20% coinsurance |
Medicare Part B Prescription Drugs | 20% coinsurance (including chemotherapy) |
Services to Treat Kidney Disease | 20% coinsurance |
Pulmonary Rehabilitation Services | $25 |
Cardiac Rehabilitation Services | $25 |
Chiropractic Services | $20 |
Acupuncture | $20 |
Podiatry Services | $25 |
Home Health Agency Care | $10 |
Inpatient Mental Health Care | $375 per stay |
Medical Nutrition Therapy | $0 |
Dental Services | $25 copayment |
Preventative Dental | Included |
Comprehensive Dental | Not covered |
Diabetes Self Management Training, Diabetic Services and Supplies | 0% - 20% |
Immunizations | $0 |
Transportation | $0 - 20 one-way trips to approved medical appointments. |
Smoking Cessation | $0 |
Hearing Services | $0-$25 and $750 per ear towards the cost of hearing aid(s) every 3 years |
Vision Care | $0-$25 and $75 plan allowance per year |
Optional Supplemental Buy-Up | Available for purchase |
Healthy Living Rewards | Not included |
COVID-19 Benefit | Acute inpatient hospital copay waived with COVID-19 diagnosis. Post hospital discharge meal delivery included. |
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 |
Gold | $0 |
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 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. There is no deductible for KelseyCare Advantage for select insulins. During the Deductible Stage, your out-of-pocket costs for these select insulins will be $30-$35 for a 30-day supply. To find out which drugs are select insulins, review the most recent Drug List.
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. There is no deductible for Select Insulins. During the Deductible Stage, your out-of-pocket costs for these Select Insulins will be $30 - $35 copay for a 30-day supply. After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,430. 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 and mail-order pharmacies.
You may get your drugs at network retail pharmacies.
Preferred Retail Cost-Sharing* | |||
Tier | 30-Day Supply | 60-Day Supply | 90-Day Supply |
Tier 1 (Preferred Generic) | $0 | $0 | $0 |
Tier 2 (Generic) | $0 | $0 | $0 |
Tier 3 (Preferred Brand) | $40 | $80 | $100 |
(Select Insulins*) | $30 | $60 | $75 |
Tier 4 (Non-Preferred Drug) | $80 | $160 | $200 |
Tier 5 (Specialty Tier) | 31% | Not Available | Not Available |
* The preferred cost-sharing pharmacies in the Greater Houston area include Kelsey Pharmacy, HEB, CVS retail locations and CVS Caremark Mail Service.
Standard Retail Cost-Sharing | |||
Tier | 30-Day Supply | 60-Day Supply | 90-Day Supply |
Tier 1 (standard Generic) | $3 | $6 | $9 |
Tier 2 (Generic) | $15 | $30 | $45 |
Tier 3 (standard Brand) | $45 | $90 | $135 |
(Select Insulins*) | $35 | $70 | $105 |
Tier 4 (Non-standard Drug) | $90 | $180 | $270 |
Tier 5 (Specialty Tier) | 31% | Not Available | Not Available |
Benefit | Description |
Mail Order | Yes |
Insulin Savings Model | Members pay no more than $35 for 30-day during any coverage stage Preferred Pharmacy: $30 Standard Pharmacy: $35 *Select Insulins in Tier 3 are covered under the plan's participation in the Part D Senior Savings Model Calendar Year 2022. To find out which drugs are Select Insulins, review the most recent Drug List we provided electronically. If you have questions about the Drug List, you can also call Member Services. |
The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,430. After you enter the coverage gap, you pay 25% of the plan’s negotiated price for covered brand name drugs and 25% of the plan’s negotiated price for covered generic drugs until your out-of-pocket costs total $7,050, which is the end of the coverage gap. KelseyCare Advantage offers additional gap coverage for Tier 1 and Tier 2 drugs and Select Insulins. 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.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay the greater of:
As part of the plan's enhanced drug coverage for Calendar Year 2022, the excluded drug Sildenafil in Tier 2 is covered. Payments you make for excluded drugs are not included in your out-of-pocket costs.
We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage).This includes coverage of the following drugs in the Tier 2 cost-sharing tier and have a quantity limit of 6 every 30 days:
The amount you pay when you fill a prescription for these drugs does not count towards drug cost for entering the Coverage Gap Stage nor does it contribute to entering the Catastrophic Coverage Stage.
The monthly plan premium to enroll in the Gold plan is $0. 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.
Members will receive most of their medical care from the doctors at Kelsey-Seybold Clinic or contracted individual provider groups. KelseyCare Advantage also contracts with an affiliate network of doctors to provide care that is not offered at Kelsey-Seybold Clinic, members are referred to an affiliate and pay the in-network cost-share. The health providers in our network can change at any time.