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2022 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

2022 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
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.
2022 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 $0
2022 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

Deductible Stage

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.

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. 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.

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 $4,430. 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.

Catastrophic Coverage Stage

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:

  • 5% of the plan’s negotiated price, or
  • $3.95 copay for generic (including brand drugs treated as generic) and a $9.85 copay for all other drugs.

Additional Prescription Drug Benefits

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:

  • sildenafil 25 MG - QL 6/30 – Tier 2
  • sildenafil 50 MG - QL 6/30 – Tier 2
  • sildenafil 100 MG - QL 6/30 – Tier 2

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
  • Preventive Dental
  • Over-the-Counter Allowance
  • COVID-19 Coverage
  • Hearing & Vision Allowances
  • $0 Tier 1 and Tier 2 Medications
  • 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

How Much Does it Cost

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.

Provider Network

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.

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