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2024 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

2024 Medical Benefits
Covered Services What You Pay
Physician Services / Doctor Office Visits PCP - $0 Specialist - $10
Annual Wellness Visit $0
Telehealth Benefit PCP - $0 Specialist - $15
Preventive Health Screenings $0
Inpatient Hospital Care $245 per stay
Outpatient Diagnostic Tests and Therapeutic Services & Supplies Diagnostic labs & x-rays $0 Advanced Radiology - $150
Emergency Care $120
Ambulance Services $100
Urgently Needed Services $5
Convenient Care Per visit: $25 CVS Minute Clinics only
OTC Allowances $90 per quarter
Flex Card $250 per year for dental, hearing and vision-related services
Outpatient Hospital Observation $150
Outpatient Surgery ASC - $125 Hospital $150
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 $20
Chiropractic Services $20
Acupuncture $20
Podiatry Services $20
Home Health Agency Care $10
Inpatient Mental Health Care $245 per stay
Medical Nutrition Therapy $0
Dental Services $0 copayment
Preventative Dental included
Comprehensive Dental 0% coinsurance up to $2,500 combined preventive and comprehensive benefit maximum
Diabetes Self Management Training, Diabetic Services and Supplies 0% - 20% coinsurance
Immunizations $0
Transportation $0 - You pay nothing. Unlimited one-way trips to approved medical appointments.
Smoking Cessation $0
Hearing Services $0 for exams and $750 per ear towards the cost of hearing aid(s) every 3 years
Vision Care $0 and $125 plan allowance per year
LiveWell Rewards Included
2024 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
Secure $0
2024 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

There is no deductible for KelseyCare Advantage drugs.

Initial Coverage

After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $5,030. 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.

Preferred Retail Cost-Sharing*
Tier  30-Day Supply 60-Day Supply 90-Day Supply
Tier 1 (Preferred Generic) $0.00 $0.00 $0.00
Tier 2 (Generic) $0.00 $0.00 $0.00
Tier 3 (Preferred Brand) $40.00 $80.00 $100.00
Tier 4 (Non-Preferred Drug) $80.00 $160.00 $200.00
Tier 5 (Specialty Tier) 33% N/A N/A
Tier 6 (Select Care Drugs) $0.00 $0.00 $0.00
Covered Insulins $35.00 $70.00 $87.50

* 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) $7.00 $14.00 $21.00
Tier 2 (Generic) $15.00 $30.00 $45.00
Tier 3 (Standard Brand) $47.00 $94.00 $141.00
Tier 4 (Non-Standard Drug) $100.00 $200.00 $300.00
Tier 5 (Specialty Tier) 33% N/A N/A
Tier 6 (Select Care Drugs) $0.00 $0.00 $0.00
(Select Insulins*) $35.00 $70.00 $105.00
Benefit Description
Mail Order Yes
Covered Insulins You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible.

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 $5,030. 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 $8,000, 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 $8,000, you pay the greater of:

  • Your plan pays the full cost for your covered Part D drugs. You pay nothing.
  • For excluded drugs covered under our enhanced benefit, you continue paying your Initial Coverage Stage cost-share.

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!

Tier 6 covers Medicare Select Care Drugs at a $0 copay, all year long, at any network pharmacy including:

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 2024, 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 2024 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
  • Preventive and Comprehensive Dental
  • Over-the-Counter Allowance and Flex Wallet
  • Hearing & Vision Allowances
  • $0 Tier 1, Tier2, and Tier 6 Medications

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

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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