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Gold Freedom

2023 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.

Download the Summary of Benefits

2023 Medical 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
Flex Wallet Card $500 for your dental, vision and hearing out-of-pocket costs
Inpatient Hospital Care $375 per stay
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 $25 CVS Minute Clinics only
Over-the-Counter Items (OTC) $95 per 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% coinsurance
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 $20
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 (Medical Only) $25
Preventative Dental $2,000 combined annual max for Preventative and Comprehensive Dental
Comprehensive Dental $2,000 combined annual max for Preventative and Comprehensive Dental
Diabetes Self Management Training, Diabetic Services and Supplies 0% - 20% coinsurance
Immunizations $0
Transportation Unlimited
Smoking Cessation $0
Hearing Services $0-$25 for exams and $750 per ear towards the cost of hearing aid(s) every 3 years
Vision Care $0-$25 and $125 plan allowance per year
Healthy Living Rewards Included. Up to $100 per year
COVID-19 Benefit Acute inpatient hospital copay waived with COVID-19 diagnosis. Post hospital discharge meal delivery included.
2023 Premiums

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
Gold Freedom $0
2023 Prescription Drug Benefits

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

Important Message About What You Pay for Vaccines- Our plan covers most Part D vaccines at no cost to you even if you haven’t paid your deductible. Call Member Services for more information.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible. Call Member Services for more information.

Deductible Stage

There is no deductible for KelseyCare Advantage drugs on tiers 1, 2, 6, formulary insulins, or formulary vaccines. 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. 

Initial Coverage

After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $4,660. 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
Tier 3 Select Insulins* $30 $60 $75
Tier 4 (Non-Preferred Drug) $80 $160 $200
Tier 5 (Specialty Tier) 31% Not Available Not Available
Tier 6 (Select Care Drugs) $0 $0 $0

* The preferred cost-sharing pharmacies in the Greater Houston area include Kelsey Pharmacy, HEB, CVS retail locations and CVS Caremark Mail Service.

** A long-term supply is not available for Tier 5 drugs.

Standard Retail Cost-Sharing
Tier  30-Day Supply 60-Day Supply 90-Day Supply
Tier 1 (Preferred Generic) $3 $6 $9
Tier 2 (Generic) $15 $30 $45
Tier 3 (Preferred Brand) $45 $90 $135
Tier 3 Select Insulins* $35 $70 $105
Tier 4 (Non-Preferred Drug) $90 $180 $270
Tier 5 (Specialty Tier) 31% Not Available Not Available
Tier 6 (Select Care Drugs) $0 $0 $0

** A long-term supply is not available for Tier 5 drugs.

Coverage Gap Stage

The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,660. KelseyCare Advantage offers additional gap coverage for drugs on Tiers 1, 2, 6, insulins, and vaccines. You will continue to pay the initial coverage stage copays for these products. Refer to the tables above to determine your copays for these products.

After you enter the coverage gap, you pay 25% of the plan’s negotiated price for covered drugs on Tiers 3, 4, and 5 until your out-of-pocket costs total $7,400, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic Coverage Stage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400, you pay the greater of:

  • 5% of the plan’s negotiated price, or
  • $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other drugs.

Additional Prescription Drug Benefits

Select Care Drugs Tier

KelseyCare Advantage is ensuring you have easy access to many of the vaccines you need and drugs you take to treat high blood pressure, high cholesterol and diabetes – all at a $0 copay!

We’ve added a new 6th Tier to our Formulary (list of covered drugs). Tier 6 covers Medicare Select Care Drugs at a $0 copay, all year long, at any network pharmacy including:

Vaccines
33 vaccinations that protect you from serious disease and illness.

Maintenance Medications
46 generic oral medications prescribed most to help you manage chronic conditions. Tier 6 drugs are covered at $0 copay all year, including during the Medicare Coverage Gap. 

Excluded Drug Coverage

We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage). This includes coverage of certain drugs excluded from Medicare Part D Coverage.

As part of the plan's enhanced drug coverage for Calendar Year 2023, the excluded drugs sildenafil 25 MG, 50 MG and 100 MG Tablet, folic acid 1 MG Tablet, ergocalciferol (vitamin D2) 1.25 MG Capsule, vitamin B12 1000 MCG/ML Injection are covered on tier 2. Payments you make for excluded drugs are not included in your out-of-pocket costs.

The covered excluded drugs in 2023 are listed below

Drug Name

Tier

Drug Restrictions

sildenafil 25 MG, 50 MG and 100 MG Tablet

2

Quantity Limit of 6 Tablets every 30 days

folic acid 1 MG Tablet

2

Quantity Limit of 30 Tablets every 30 days

ergocalciferol (vitamin D2) 1.25 MG Capsule

2

Quantity Limit of 4 Capsules every 28 days

vitamin B12 1000 MCG/ML Injection

2

Quantity Limit of one vial 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.

Plan Summaries

  • Medical Coverage
  • Prescription Drug Coverage
  • Comprehensive Dental
  • Over-the-Counter Allowance
  • COVID-19 Coverage
  • Wellness Benefit Allowance
  • Flex Wallet Card
  • Hearing & Vision Allowances
  • $0 Tier 1 and Tier 2 Medications
  • No Referrals for Out-of-Network Services
  • And more

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

How Much Does it Cost

The monthly plan premium to enroll in the Gold Freedom 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.

 


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